6—THE ART OF PATIENT SELECTION AND SHORT- AND LONG-TERM MANAGEMENT
39
Patients who are older at presentation do especially well if they can first ‘put the clock back’
with CO2 laser and blepharoplasties, then maintain movement and volume with filler and botu
linum toxin.
If the patients have thin narrow lateral orbital rims, perhaps with prominent veins, they are
sometimes advised to avoid botulinum toxin to their crow’s feet, to maintain the more youthful
Image of Fig. 6.10
Image of Fig. 6.10
Fig. 6.10 (A) Before treatment and (B) in this edition, 15 years later.
Image of Fig. 6.9
Image of Fig. 6.9
Fig. 6.9 (A) Before treatment and (B) 15 years later.
Image of Fig. 6.11
Image of Fig. 6.11
Fig. 6.11 (A) Forehead in 2003. (B) Forehead in 2018.
40
BOTULINUM TOXIN IN FACIAL REJUVENATION
muscle bulk. They may be suitable for fine hyaluronic acid filler or liquid fat to restore their rim
volume. Static lines are treated with regular CO2 laser and paraben-free Retin-A.
Long-term treatment is always planned with the effects of neuromodulation in mind. The
patient learns, when observed before repeat treatments, that certain compensating muscles be
come too strong after a while and need to be weakened. For example, treatment of the glabellar
complex for ‘scowling’ often diverts signalling to the lateral brow and when patients raise their
brows, they manifest a ‘peak’ over the lateral aspect (Fig. 6.12). They will understand that the
Image of Fig. 6.12
Image of
Fig. 6.12
Fig. 6.12 (A) Lateral frontalis. (B) Diagram of lateral frontalis.
6—THE ART OF PATIENT SELECTION AND SHORT- AND LONG-TERM MANAGEMENT
41
same muscles must not be continuously treated and that certain muscle complexes need to be
allowed to recover and bulk up. This is to get the desired resting tone, natural brow position
(without excess frontalis underaction) and a natural facial expression without static rhytids.
Long-term management is sometimes served best with multiple dilute injections layered on
the anterior surface of the muscle, just beneath the dermis, accompanied by the occasional deeper
intermuscular injection.
PSYCHOLOGICAL ASSESSMENT
The physician must develop a keen instinct when assessing patients for cosmetic botulinum toxin,
in particular, the patient’s psychological suitability and comprehension.
Aesthetic treatments, unlike medical ones, are not essential and can be refused at any stage.
The initial consultation should identify patients who are poorly equipped psychologically to deal
with changes in their appearance.
Every patient is entitled to follow-up consultations after he or she has received a treatment,
regardless of the medical necessity of the visit. If a patient becomes distressed by the new shape of
his or her eyebrows, it is important to be available to counsel and reassure him or her until the effect
of the botulinum toxin has worn off. This is a rare occurrence but may even entail daily appointments
for the first week, followed by weekly appointments for reassurance until the toxin has worn off.
GUIDELINES APPLICABLE TO ALL COSMETIC MEDICAL
AND SURGICAL TREATMENTS
The first point of contact in a cosmetic practice may be the practice manager who books appoint
ments and deals with patients’ accounts. They too are trained to detect potentially challenging
(unrealistic expectations, poor comprehension) patients. Patients frequently see an aesthetic nurse
before their medical consultation. An experienced practice nurse can cancel a treatment plan for
an unsuitable patient. The patients who eventually see the physician are usually ideal for treat
ment, but some are still deemed unsuitable at the time of consultation because of unachievable
expectations or, more frequently, lack of psychological reserves to deal with a risk at that particu
lar moment in time. Such patients may have their first treatment postponed and be given an
appointment for review. A typical reason for postponement would be a recent bereavement.
There are obvious reasons for refusing certain patients even though they are physically suitable
for botulinum toxin, but more subtle ones should also be considered.
The decision not to treat is always based on the possibility that the patient will not be happy
with what the treatment will do—even if they think they will!
Ask yourself, before every new treatment, will this make this patient happy?
If not, why not?
SOME REASONS FOR POOR PATIENT SATISFACTION DESPITE
A GOOD RESULT
Poor Comprehension
Patients who cannot understand risks or side effects despite repeated explanations often reveal
themselves only after the first treatment, by telephoning the next day to say that it ‘hasn’t worked’,
or 14 weeks later to complain that the ‘wrinkles have returned’ despite advice about the time of
onset and duration.
It is important for a clinician to understand that people have different ways of processing
information. Most patients fall in to one of three, or a combination of three, categories: auditory
understanders, visual understanders or tactile understanders.
42
BOTULINUM TOXIN IN FACIAL REJUVENATION
A ‘visual understander’ grasps information quickly from pictures (e.g. pretreatment and post
treatment photographs), and they may not often ‘hear’ what is being said whilst taking in the
image; an auditory understander ‘hears’ what is being said but quickly becomes saturated if shown
more than one or two images; and a tactile understander has their information reinforced with
processes, such a leafing through a brochure or filling out a form after learning of risks. It is the
responsibility of the practitioner to provide enough information so as not to be misunderstood.
Unreasonable Expectations
Patients with unreasonable expectations often argue with the physician. For example, if shown how the
brows might peak if their glabella alone is treated, they might disagree and continue to request
the glabella treatment on its own. These patients also often reveal poor comprehension and deserve
the extra time needed to allow them to fully understand what would be possible with their treatment.
Care must be taken to document in detail all consultations, with written information, photog
raphy and a good signed consent form. Certain patients may not remember ever being given
information and have been known to inadvertently misrepresent medical advice.
The close friends of patients or their siblings can also have unreasonable expectations. One
sibling, with a family resemblance, may marvel at the other’s result and expect the same cosmetic
result. It can be hard to point out that their sibling is a natural beauty with symmetrical features
and good skin tone, whereas they, although rather alike, have lower heavier brows with asym
metrical frontalis action and sun-damaged skin!
Some patients are referred by other patients, expecting the same result as their friend. Care
must be taken to explain the expected differences in results, while never referring to their friend
or acknowledging that their friend really is a patient.
Depression
Recent research shows that botulinum toxin may actually reverse depression, by alteration of
central neurotransmitter levels.
Depression is greatly underdiagnosed. Both reactive and endogenous types are relative contrain
dications to treatment. A depressed patient may speak slowly and seem ‘flat’ during the consultation.
They may have suffered a recent bereavement, separation or divorce. Those who experience such life
crises often review themselves. They notice their appearance, decide that they have ‘let themselves go’
and fix up a botulinum toxin appointment. Some become tearful during the consultation.
There are two good reasons for hesitating to administer rejuvenating botulinum toxin treat
ment to depressed patients. The first is the risk associated with every procedure; an unusual com
plication could deepen their depression. The other is that many patients, even mildly depressed
ones, have poor powers of concentration, so they find it hard to assimilate medical advice.
The subject of their depression may be gently broached. Cosmetic treatment options may be
discussed but perhaps accompanied with a suggestion to postpone the treatment until they are
better. Psychological and medical counselling may be recommended, perhaps with a referral to
their general practitioner for a psychiatric referral. Time is well spent discussing the way the body
behaves with depression and the forms of treatment available. These patients usually return when
they are better and are often suitable then for cosmetic procedures.
It is true that some depressed patients do cheer up when botulinum toxin eliminates their
frown, but care should be taken about the timing of such treatments. Above all, they must be
deemed healthy enough to provide informed consent.
Dysmorphophobia
This is rare but seen at every cosmetic clinic. It has various degrees of severity, and patients
require a psychiatric referral—if they will agree to one. Avoid treating such patients without a
report from their psychiatrist.
6—THE ART OF PATIENT SELECTION AND SHORT- AND LONG-TERM MANAGEMENT
43
An example of a dysmorphophobic patient is one who came to the author for the management
of an eyelid ‘wrinkle’. There simply was no wrinkle where she pointed. In another, the normal
lower lid morgagnian crease (between the pretarsal and tarsal orbicularis) was the offending
wrinkle.
Such patients often refuse to look in the mirror during the consultation and almost always
become distressed if attempts are made to photograph them. It is useful to remember that even
though the defect identified by the patient is not apparent to the objective viewer, the patient may
continue to view it as a problem whether it is treated or not. Some patients will have received
numerous cosmetic treatments elsewhere at enormous expense. The ethics of this are debatable.
USER TIP
Avoid joint consultations (i.e. seeing two friends at the same time). Welcome a ‘second ear’ if
necessary and let a friend sit in, but it is difficult to assess a patient’s mental suitability for a
procedure when speaking to two people at once.
44
C H A P T E R 7
Contraindications
and Complications
The right way to select patients for treatment with botulinum toxin (BTX) is described
in detail in Chapter 6, and some well-established contraindications must always be kept
in mind.
Absolute Contraindications
Anything that interferes with the predicted response to BTX, which inhibits the release of
acetylcholine at the neuromuscular synapse (Fig. 7.1).
a. Drugs and disorders which also reduce acetylcholine at the motor end plate, amplifying the
action of BTX:
n Eaton-Lambert antibodies. Note a history of cancer, metastases and general lack of well-
being which may suggest a diagnosis of Eaton-Lambert syndrome (see ‘Neuromuscular
Disorders’).
n Aminoglycosides (gentamycin, streptomycin, kanamycin) act on the presynaptic
neurone.
b. Drugs and disorders which alter the response of the motor end plate, amplifying the action
of BTX:
n Myasthenia gravis alters and reduces the acetylcholine receptors on the motor end plate
(see section on ‘Neuromuscular Disorders’).
n Medication with succinylcholine (an agonist blocker) produces a prolonged depolarisa
tion with reduced contraction.
n Tubocurare, pancuronium and gallamine are antagonist blockers that compete with
acetylcholine for end-plate receptor sites.
n d-penicillamine can produce myasthenia gravis–type antibodies.
Drugs which reduce the action of BTX
The antimalarials chloroquine and hydroxychloroquine, and the immunosuppressant cyclo
sporin, can reduce the action of BTX.
Neuromuscular disorders
It is of paramount importance to avoid BTX in patients with neuromuscular disorders. Many
such disorders are inherited and so a thorough family history must be taken with this point in
mind.
General and local anaesthesia
Administering BTX at the time of general or local anaesthesia gives less predictable
results. Avoid injecting BTX to the eye zone in patients who have had local anaesthesia for
blepharoplasty.
Also avoid giving BTX in the postoperative phase where there is local oedema, to reduce the
risk of distal diffusion and, for example, perioral palsy.
7—CONTRAINDICATIONS AND COMPLICATIONS
45
Image of Fig. 7.1
Fig. 7.1 Normal cholinergic transmission and action of botulinum toxin (BTX) at the neuromuscular junction: effects of drug and disease interactions (circled numbers).
(1) Calcium channel blockers: aminoglycosides, cyclosporin; (2) tumour antigen antibodies block calcium channels (Lambert-Eaton syndrome); (3) block binding of
BTX heavy chain to synaptogamin: chloroquine and hydroxychloroquine; (4) block nicotine receptor antibodies, e.g. myasthenia gravis, d-penicillamine; (5) postsynaptic
acetylcholine antagonist: tubocurarine, gallamine, pancuronium. Agonist blocker: succinylcholine.
Continued
46
BOTULINUM TOXIN IN FACIAL REJUVENATION
Image of Fig. 7.
1
Fig. 7.1, cont’d
7—CONTRAINDICATIONS AND COMPLICATIONS
47
Contraindications:
Eaton-Lambert syndrome
Myasthenia gravis
Neuromuscular disorders (check family history).
Aminoglycosides (streptomycin, gentamycin, kanamycin)
Certain drugs used during anaesthesia (e.g. succinylcholine, tubocurare)
d-Penicillamine—used in rheumatoid arthritis
Chloroquine, hydroxychloroquine (antimalarials)
Cyclosporin (immunosuppressant)
Pregnancy
Infection
PREGNANCY AND BREASTFEEDING
The teratogenicity of BTX has not yet been established and so it is contraindicated in pregnancy
and during breastfeeding. There are reports in the literature of dozens of women who inadver
tently received BTX whilst unknowingly pregnant. One percent miscarried, and there appears to
be no obvious association.
ALLERGY
A history of allergy to any ingredient in the formulation, including albumin. Reports of allergic
reactions include local rashes. For noncosmetic patients requiring BTX (e.g. with cervical dysto
nia), IncaBTX-A (Xeomin), with its lower protein load, may prove a safe alternative but must be
used judiciously.
USER TIP
Search the patient’s history for any hint of muscle or nerve weakness that he or she may not
be aware of. Enquire about episodes of intermittent drooping of the eyelid.
USER TIP
Take care to document that the patient has denied any contraindications.
Relative Contraindications
Many patients who come for BTX treatment for rhytids are self-referred. Their motivation is
based either on a drive for self-improvement or a desire to ‘have what their friend has had’, that
is a wrinkle-free forehead. Reserve judgement on their suitability for treatment until a careful
assessment has been carried out. This is dealt with in detail in Chapter 6, and most of the
side effects discussed can be avoided by rigorous patient selection. In addition, patients must be
provided with detailed written information about the poisonous nature of BTX and the other
risks associated with treatment.
If fully informed, most patients have reasonable expectations. Once in possession of all the
facts, they are in a position to decide what risks to take and when. They may be happy to risk
walking down the aisle with a camouflaged bruise or may prefer to postpone this risk until after
their ‘big day’ and opt to keep their frown instead. If their treatment will be unpredictable (e.g.
the treatment of a deep frown in a patient with moderate lash/brow distance and a moderate
48
BOTULINUM TOXIN IN FACIAL REJUVENATION
transient risk of immobile brows), then let them know about this. They can always change the
date of their appointment to avoid it clashing with a big occasion.
USER TIP
Avoid treating patients who cannot fully understand the risks being discussed.
Table 7.1 lists the most frequent complaints encountered in the author’s practice during more
than 30 years of treatments with BTX for rhytids. During this time, the incidence of complaints
has dropped dramatically, probably as a result of more rigorous patient selection and counselling,
but also generalised public awareness.
Patient Complaints
COMPLAINT: IT DIDN’T WORK
Dysport and Azzalure usually start to work within 24 hours, but it is advisable to warn patients
that results are not immediate and that they may notice nothing for up to 5 days.
It is possible to get a bad batch of toxin, causing a primary failure, albeit very rarely. Producers
will replace a faulty vial immediately, free of charge, but rarely have to do so. Take care not to
agitate the solution, and to follow storage guidelines carefully. The most likely cause for a failure
of the toxin to work is inappropriate handling of it.
See the patients as soon as possible. Confirm that their treatment has not worked. It is wise
to examine your files for other patients who received treatment from the same batch.
Offer to re-treat at no extra cost and reexamine within 2 weeks. If there is still no effect, advise
the patients that they are resistant to the toxin and will have to pay for any further treatment
using alternative toxins.
USER TIP
Advise patients to reattend with their complaint—but not earlier than 1 week and not later
than 3 weeks.
Complaint
Most Likely Cause
It didn’t work!
BTX denatured.
It didn’t last!
BTX too dilute or too old.
I’m still frowning!
Patients do not understand what you have told them about
their low brows and the treatment of frown! (see Chapter 9)
Patient looks tired
BTX to forehead causes brow ptosis.
My eyes are swollen!
Due to protrusion of upper and lower lid orbital fat and skin
from weight of flaccid brows and flaccid lower septum.
Hollow socket
BTX to inferolateral canthus in certain patients.
Peaked eyebrows
BTX over 75% of medial brow only.
Epiphora
BTX over lacrimal pump.
Severe bruising
BTX over branch of maxillary vein.
Unnaturally wide palpebral aperture
BTX to pretarsal orbicularis muscle.
BTX, Botulinum toxin.
TABLE 7.1 n Patients’ Complaints After Injections of Botulinum Toxin for Their Rhytids
7—CONTRAINDICATIONS AND COMPLICATIONS
49
COMPLAINT: IT DIDN’T LAST
Examine the patient if possible, but this complaint is usually made at a follow-up visit. Check
the batch used and the other patients treated with it. The patient is usually right. The most likely
cause will be excessive dilution of the BTX or denaturation by agitation or the wrong room tem
perature.
Reassure the patient. Consider reinjecting, but avoid doing so too frequently (i.e. within
12 weeks), to avoid the risk of stimulating antibody formation (see below). Use a different
brand, a different strength or more sites, next time.
USER TIP
Patients who have suffered facial nerve paralysis (e.g. facial palsy) need smaller doses than
often mandatory for effect because their facial muscles will be very sensitive to botulinum
toxin following their denervation.
COMPLAINT: ‘I’M STILL FROWNING’
Examine patients within 3 weeks but not before 10 days. This allows the toxin to take effect. Give
more BTX if stray residual active fibres are genuinely visible. Spend more time on counselling if
the result is what you have aimed for, that is some residual brow movement and lift in a moderate
to low-browed patient.
Do not give more toxin to the lateral frontalis against your better judgment. A tired-looking
patient will be far less happy than a partially frowning one.
COMPLAINT: THE PATIENT LOOKS TIRED
This is due to an unexpected lack of brow movement in a moderately low-browed person. It can
also occur when BTX diffuses too far medially. The tonic orbicularis under the eyelid is loosened,
allowing the infraorbital fat pad to protrude (see Fig. 6.6).
Spend time reassuring patients that the maximum effect is transient and that the extra muscles
involved have received only the ‘edge’ of the treatment as the toxin diffused. This means that they
will recover much sooner than the central muscles and that a tired look rarely lasts for more than
4 weeks. Increase brow movement with scalp aponeurosis exercises.
COMPLAINT: ‘MY EYES ARE SWOLLEN’
A sudden onset of swelling and puffiness around the eyes, if pathological, is almost always due
to allergy (associated with itch, hay fever, etc.) or infection (associated with erythema, pain,
temperature). In the author’s experience a local allergic reaction to BTX is uncommon, although
this can occur in those who react to albumin. Care must be taken in the 601 age group. Such
patients have greatly reduced elasticity and tone. This results in sagging of the forehead skin
(causing brows to drop) and sagging of the periocular skin (causing upper and lower lid bags).
Many patients use their frontalis muscle to suspend the sagging brows and upper lids. They
hold their forehead muscle in a permanent frown, causing high arching brows and nice deep up
per lids. Treatment of such a frown with BTX will automatically relax the frontalis, throwing their
brows down and their lid skin onto their lashes. These patients may complain of droopy lids and
‘swelling’ over their eyes due to BTX, when in fact it is simply the skin sagging because the brow
position has been lowered. Try to demonstrate this possibility to the patient by manually pressing
their brows down. Avoid BTX unless blepharoplasty and/or brow lift has been performed.
50
BOTULINUM TOXIN IN FACIAL REJUVENATION
Swollen eyes after BTX mean that the natural orbital fat and skin folds have protruded.
Demonstrate this to the patient by asking them to look in a mirror with their head tilted upwards,
a position that allows the fat to sink back into the sockets. Also lift the brows up actively with
your hands while they watch the effect in the mirror. Reassure as described previously.
COMPLAINT: PEAKED EYEBROWS
This is dealt with in Chapter 9. Incomplete paralysis of the frontalis muscle is often chosen to
achieve a natural effect. The aim is to retain some forehead movement while freezing the frown.
The problem is that residual active frontalis fibres may sometimes, unpredictably, distort the
shape of the brows. A symmetrical treatment may result in asymmetric brow peaking (Fig. 7.2).
Some patients have naturally asymmetrical eyebrows: others experience contralateral overaction
of untreated frontalis fibres as the opposite side fails to respond to stimulation. This is common
in squint patients whose eye muscles work as part of a yoke mechanism. Contraction of the
medial rectus on one side is associated with contraction of the contralateral lateral rectus. Under
activity of one muscle, for example the lateral rectus due to abducens palsy, will result in overactiv
ity of the opposite medial rectus (Herring’s law).
Examine your patients carefully before starting treatment. Try to predict asymmetry (see
Chapter 5). It is best to give an initial symmetrical treatment with a view to ‘balancing’ the effect
within 2 weeks of the first treatment (Fig. 7.3A and B). Very little BTX is needed to achieve the
correct effect (e.g. 0.025 mL [see dose box]) subcutaneously. Avoid using too much, because this
can cause brow ptosis.
USER TIP
Individual facial muscles can be heavily interwoven or merge with neighbouring muscles, with
plenty of anatomical variants.
COMPLAINT: A DROOPY EYELID
Ptosis is the term used for a droopy eyelid. The distance from the lower lid margin to the upper
lid margin (the palpebral aperture) varies. Some patients have visible sclera below and above their
limbus (edge of the cornea). This may occur naturally in myopic patients with naturally large eyes,
in patients with thyroid eye disease or in those with unusually shallow orbits.
Fig. 7.2 Unnatural brow peaking following botulinum toxin to glabella in a patient with overactive lateral
frontalis fibres.
7—CONTRAINDICATIONS AND COMPLICATIONS
51
The eyelid is elevated by the levator palpebrae superioris muscle (normal range is 17 mm from
looking down to looking up) and Muller muscle—a supratarsal collection of involuntary smooth
muscle fibres. The voluntary levator muscle elevates the lid, while Muller muscle is responsible
for fine tuning lid height and ‘setting’ it. Muller muscle is responsible for only 2 mm of lid height,
and therefore paralysis (e.g. in Horner syndrome) causes only 2 mm of ptosis.
Image of Fig. 7.3
Fig. 7.3 Drawing to demonstrate correction of inadvertent lateral brow peaking. (A) suggests how to correct
lateral brow peaking and (B) suggests how to correct medial brow peaking.
52
BOTULINUM TOXIN IN FACIAL REJUVENATION
The upper eyelid margin of most patients rests 2 mm below the limbus and is symmetrical.
Unilateral ptosis will often result in a raised eyelid on the other side, and likewise the illusion
of ptosis can be created by unilateral lid retraction causing lowering of the opposite lid
(Herring’s law).
USER TIP
Always look for lid symmetry before giving botulinum toxin.
Congenital ptosis is relatively common (Fig. 7.4A and B) and age-related ptosis even more
so. The latter is due to involutional weakening of the levator muscle attachments. It can be subtle
at first (i.e. ,1 mm) and is usually associated with elevation of the lid crease as the skin–muscle
attachment separates from the original crease. Ptosis is often worse in the evening, and, in age-
related ptosis, the eyelid will be lower than the normal lid on looking down (Fig. 7.5A and B).
It is important to note that patients with levator aponeurosis disinsertion (age-related ptosis)
usually raise their eyebrows to ‘hold’ the lid height. This can be a subtle change, and failure to
detect it prior to BTX treatment will result in the unmasking of a preexisting ptosis.
There have been several reports of ptosis due to BTX, but some of these refer to brow ptosis,
not to true ptosis. Brow ptosis will occur in any patient with an overactive frontalis muscle and
involutional descent of the brows. It is not due to BTX to eyelid muscles, although brow ptosis
can lead to an eyelid being pressed to a lower height by the simple effect of the weight of the
brow on it. This can be identified by replacing the brows manually and observing the return of
normal lid height.
True ptosis following BTX is due to inadvertent treatment of the levator palpebrae superioris
muscle. Reported incidents occur if toxin diffuses through the orbital septum and usually last less
than 2 weeks. The incidence is low and the author has seen only one case over years of experience
with BTX, perhaps as a result of avoiding the levator muscle and never injecting medial to the
Image of Fig. 7.5
Image of Fig. 7.5
Fig. 7.5 (A) Age-related ptosis before anterior levator reinsertion. (B) After surgery.
Image of Fig. 7.4
Image of Fig. 7.4
Fig. 7.4 Congenital ptosis: (A) before surgery and (B) after surgery.
7—CONTRAINDICATIONS AND COMPLICATIONS
53
lateral orbital rim. Unless experienced, practitioners should avoid injecting the corrugator muscle
from the inferior aspect of the brow, particularly in patients with a low lash/brow distance.
Treatment of botulinum-induced ptosis is reassurance, reminding the patients that it will
recover as the BTX wears off. Some recommend using Apraclonidine 5% (Iopidine) eye drops
to stimulate the Muller muscle. This will result in a temporary elevation but only of 2 mm. Apra
clonidine is an alpha-adrenergic stimulator used to reduce intraocular pressure and has several
ocular side effects: its use in the treatment of transient ptosis occurring as a result of a cosmetic
application of BTX is therefore questionable. The risks posed to the eye by use of apraclonidine
must be balanced against the fact that the ptosis will undoubtedly recover when the botulinum
wears off.
COMPLAINT: A WATERY EYE
Epiphora means a ‘watery eye’. It is an unusual complaint but can either be due to paralysis
of the lacrimal pump or to paralysis of the lower lid orbicularis.
Paralysis of the medial pretarsal orbicularis prevents the suction of tears into the lachrymal
sac that normally occurs with blinking. It is often seen with Bell’s palsy. It can be avoided by not
injecting BTX medial to the mid-pupil line.
Another cause of epiphora is excessive laxity of the inferior pretarsal orbicularis.
The resting tone of the muscle is reduced and so the height of the lid drops. The increased
palpebral aperture may undermine the normal tear film. The tear film break-up time may in
crease, and the ocular area exposed to the atmosphere may be too great for the volume of tears
produced. This results in inadequate lubrication of the eye (a dry eye) BUT manifests itself as
epiphora. When the eye is dry, the blink reflex causes the lid to pass over a dry surface, creating
‘microscratches’ on the cornea. This stimulates trigeminal nerve fibres and results in tears and a
watery eye. Unfortunately, this reflex flow of tears is often not enough to cure the dry eye and
may be accompanied by a gritty sensation. Remember that a reduction in the tear film, and mildly
dry eyes, are common in menopausal women.
The treatment of epiphora due to pump inaction is to wait until the BTX wears off. The
treatment of a dry eye is lubrication. Recommend over-the-counter preparations such as Tears
Naturale, Artelac or Liquefilm. More viscous agents, such as Vidisic gel or gel tears, help if the
patient is outdoors and at night. Lacrilube (petrolatum eye ointment) may be recommended in
severe cases for use at night. If these measures fail, consider referral to an ophthalmologist for
other types of management such as temporary lacrimal plugs.
OTHER COMPLAINTS IN TABLE 7.1
These are dealt with in Chapters 8 and 9. Experience in the art of BTX use will help to avoid
them, and I rarely encounter them now. Having said that, Fig. 7.6 shows a recent patient who
had BTX prior to lower lid blepharoplasty. Recommend a suitable camouflage cream.
Side Effects
The side effects of BTX are usually minimal: one of the deadliest poisons known to mankind is
also one of the safest when used correctly.
USER TIP
Lessen the risk of developing resistance by avoiding booster injections and treatments less
than 3 months apart. Use the smallest dose necessary.
54
BOTULINUM TOXIN IN FACIAL REJUVENATION
RESISTANCE
Most reported side effects follow the injection of toxin at high doses for the treatment of cervical
dystonia and other large-muscle disorders. Antibody production has not been reported in patients
receiving less than 50 units BOTOX. In one study, the production of immunoglobulin G auto
antibodies occurred in 4.3% of patients receiving BTX for torticollis. Those who have developed
antibodies to type A should still respond to other serotypes. It is noteworthy that no resistance
has been reported in patients receiving BTX for aesthetic reasons, but as patients receive higher
doses to include neck rhytids, the risk of resistance must be kept in mind. Current advice is to
avoid repeating injections within 3 months and to avoid booster injections
USER TIP
Botulinum toxin should be fixed inside intracellular tissues after 48 hours.
GENERAL
Patients have complained of generalised side effects, such as a ‘flulike’ illness and headache.
Certain rare side effects such as generalised muscular weakness are believed to be due to the
dissemination of BTX via the blood stream. There are electromyographic studies demonstrating
contralateral effect for large doses for dystonia, presumably travelling retrogradely through the
spinal cord. It is of paramount importance to avoid BTX in patients with neuromuscular disor
ders. BTX does not cross the blood-brain barrier.
Dysphagia can occur after the injection of BTX for cervical dystonia and is due to local dif
fusion from the injection site. The use of low-volume doses at high concentrations will limit this.
Dysphagia has been reported following cosmetic use in the neck: neck weakness has also been
reported. These symptoms usually subside after 2 to 3 weeks.
Bruising is an inevitable side effect of any intramuscular injection. Cutaneous vessels can be
seen and avoided, but patients must accept the risk of ecchymoses from hidden vessels. Bruising
in the lower lid can track down to the neck. Compress the injection site immediately after treat
ment and apply ice. Avoid injecting patients taking aspirin, nonsteroidal antiinflammatory
preparations or Ginkgo biloba—a homeopathic inhibitor of platelet function—to reduce the risk.
Fig. 7.6 Bruising following botulinum toxin injection to
lateral canthus.
55
C H A P T E R 8
Management of Crow’s Feet
‘Crow’s feet’ are the wrinkles that form with age at the outer corners of the eyes. They are due to
contraction of the orbicularis oculi muscles (Fig. 8.1). Their treatment with botulinum toxin is
usually straightforward, but certain aspects must be considered carefully first.
The functions of the orbicularis oculi muscle are to close the eye, to drain the tear film and to
create facial expressions. Contraction of this muscle can also drag on the lateral third of the eye
brow, contributing to drooping of the brow with age. In addition, the resting tension of the orbi
cularis oculi muscle can increase with age and character.
Many patients keep tension at the angle constant and so have pleasant ‘smiling eyes’. This
tension can be important to the appearance of the patient: it results in rhytids but also supports
an ageing midface in some patients. It can also prevent the protrusion of age-related lower lid
‘bags’ (orbital fat) by supporting the orbital septum.
Injections of botulinum toxin will smooth out the rhytids and make the skin look younger, but
patients may begin to look ‘thin’ around their eyes as they lose muscle bulk after repeated injec
tions. They may also look ‘drawn’ or tired as their midface falls over the zygomatic arch. Such
changes usually do not become apparent until several treatments have been undertaken. The loss
of tension can reverse with time because the orbicularis muscle rarely atrophies permanently; this
has been shown by the results of long-term botulinum toxin treatment of orbital blepharospasm.
This chapter covers the assessment and treatment of crow’s feet. However, it is important to
reexamine patients before every treatment and to make sure that they will still look well because
of it. Make certain that the botulinum toxin can do for the patient what the patient expects.
Image of
Fig. 8.1
Fig. 8.1 Anatomy of orbicularis oculi muscle.
56
BOTULINUM TOXIN IN FACIAL REJUVENATION
USER TIP
Botulinum toxin will paralyse the orbicularis muscle, making it flaccid and even atrophic. This
will stop wrinkles, but the loss of muscle tone will not suit everyone.
Patient Examination
Examine patients both from the front and the side.
Examine them at rest and when smiling.
Try to imagine what relaxation of their orbicularis muscle will do to their appearance.
What to Look for When Examining a Patient
n Examine the tone of the orbicularis oculi muscle and the position of rhytids. Are the wrinkles
deep? Spread the skin gently between your fingers. Are they still very obvious? If they are, tell
patients that they might not notice much effect from the treatment. Advise them about laser
resurfacing and skin management. If the wrinkles are mild, advise patients that they might get a
permanent effect with time and good skin care (Fig. 8.2A and B).
n Examine the facial skin and muscle tone by asking patients to smile while pressing lightly on
the zygomatic arch with two fingers (Fig. 8.3A and B). This stops the orbicularis muscle from
contracting and so simulates the paralysis of botulinum toxin.
n Patients with severe sun damage or poor skin tone (often older patients) will observe that,
on smiling, the cheek and orbicularis oculi muscles elevate the facial skin and send it into
folds around the lateral orbit. Show patients that this will also happen after botulinum toxin
treatment to the crow’s feet, otherwise they will think that the injections have not worked.
It is often wisest not to treat such patients unless they have had surgical or laser correction
of skin tone.
n The Mickey Mouse sign: occasionally, patients (especially men older than 50 with good skin tone)
notice that smiling causes their wrinkles to ‘bunch up’ at the level of the zygoma after treatment
of their crow’s feet. This can create a curved wrinkle running from the lower orbital rim, out along
the inferior border of the orbicularis oculi, over the zygomatic arch, to the top of the orbicularis
oris (the Mickey Mouse smile). The periocular fibres have atrophied as planned, but the resting skin
tone prevents elevation of the periocular skin and muscle on smiling. However, the excessive tone
of the orbicularis oris, associated with thinning of lateral orbicularis oculi fibres, makes the smile
appear much wider than the upper face. Take care with such patients.
Image of Fig. 8.2
Image of Fig. 8.2
Fig. 8.2 One year before (A) and 1 year after (B) BOTOX to crow’s feet.
8—MANAGEMENT OF CROW’S FEET
57
n Examine the contour of the socket. Is it shallow, allowing anterior displacement of orbital fat and
bags? Does the inferior orbital rim protrude? Is it recessed behind the level of the anterior surface
of the cornea? This may also be assessed by the ‘pencil test’. Ask the patient to hold a pencil verti
cally against the anterior cheekbone. If this passes in front of the cornea (Fig. 8.4A), then the patient
has good lower lid skeletal support. If the pencil reaches only the lash margin (see Fig. 8.4B), before
it would penetrate the globe, then the patient is at risk of developing sagging of the lower lid and
widening of the palpebral aperture if botulinum toxin is injected for pretarsal orbicularis wrinkles.
n Examine the height and width of the zygomatic arch. Does the orbicularis muscle sag between
the cheekbone and the eye? Will this area develop a hollow appearance if the muscle becomes
Image of Fig. 8.3
Image of Fig. 8.3
Fig. 8.3 (A) Press finger on zygomatic arch and ask patient to smile. This demonstrates the orbicularis
muscle NOT contracting as if treated with BTX. (B) Push up skin from midface over zygoma. This demon
strates the effect of “smiling” on the midface and crows feet, independent of a BTX effect, in older skin.
Image of Fig. 8.4
Image of Fig. 8.4
Fig. 8.4 (A) Typical bone structure means that a pencil will pass from the maxilla to in front of the cornea.
(B) Some patients have a maxilla which receded from the inferior orbital rim. A pencil will pass from the
maxilla through the eye. This means that inferoorbital contents (muscle and fat) are prone to bulging in front
of the orbital rim, creating ‘bags’.
58
BOTULINUM TOXIN IN FACIAL REJUVENATION
thinner? Such a hollowing can be unattractive if accentuated (Fig. 8.5). Discuss this and inject
more laterally to avoid diffusion to the ‘hollow’.
n Take special care over patients with large eyes and wide, high cheekbones (e.g. Fig. 8.6).
They are also, because of their large eyes, at high risk of sagging of the lower lid. The lower lid
normally elevates with smiling as the palpebral aperture narrows and the orbicularis oculi
contracts. Botulinum toxin will allow a more wide-eyed smile. This is often attractive, but
never when the lateral corner of the lid falls below the medial, creating a pseudo lateral canthus
inversus.
n Look for a weak orbital septum or protruding orbital fat pads. Ask patients to put their
chin down and then to look up into the mirror—this will accentuate lower orbital fat pads.
If fat protrudes, DO NOT treat the skin under the eyelid, because the subsequent loss of
tone will cause temporary deterioration of the bags. These patients should have lower lid
blepharoplasty and understand that only the wrinkles at the sides of their eyes will benefit
from botulinum toxin.
Side Effects of Botulinum Toxin Treatment
for Crow’s Feet
These may occur if the injections are placed in the wrong part of the muscle, given at the wrong
dose or given with unrealistic expectations. They are listed in Table 8.1.
TEAR FILM
Botulinum toxin to the eye zone can affect the tear film in two ways: the need for tear film may
increase and the drainage of tears may be reduced.
Increased Need for Tear Film
Weakening of the pretarsal orbicularis widens the palpebral aperture. This may aggravate an
already compromised tear film by increasing the area requiring lubrication and by reducing the
rate of reflex blinking. Such patients may complain of a dry gritty feeling or, more likely, of watery
Fig. 8.6 Large eyes, wide, high cheek
bone: Botulinum toxin close to the lower
lid will weaken elevation of the lower lid
and may increase the lateral palpebral
fissure, creating a flat lateral lid instead
of being angled above the height of the
medial canthus.
Fig. 8.5 Hollowing after botulinum toxin treatment.
Avoid giving botulinum toxin on or medial to the
infraorbital zygoma in a patient with high, broad
cheekbones. This would cause atrophy of overly
ing orbicularis and subsequent hollowing. Note
hollowing (arrow).
8—MANAGEMENT OF CROW’S FEET
59
eyes. This is because drying of the eye causes the eyelid to scrape over the cornea and sclera,
creating micro-epithelial defects and a sensation of grittiness. The resulting corneal stimulation
provokes involuntary epiphora and a watery eye.
These patients should increase their artificial lubricants or lubricate occasionally with a gel
substitute until the botulinum toxin wears off. Many lubricants are available without prescription,
and the trick is to use them frequently initially, then to wean them off according to symptoms.
Reduction of Drainage of Tears
Botulinum toxin can be injected into the pretarsal orbicularis to reduce a hypertrophic orbicularis
muscle and early ‘bagging’ (Fig. 8.7). However, it should never be injected close enough to diffuse
towards the lower lid punctum. This would paralyse the lacrimal pump, causing a watery eye—
unless, luckily, the patient was already suffering from a dry eye.
The lacrimal pump (Fig. 8.8) comprises fibres from the orbicularis that insert onto the verti
cal portion of the canaliculus and the lacrimal sac. Blinking contracts these fibres and dilates the
canaliculus and sac. This creates a negative pressure drawing the tears along the lower lid margin
into the lacrimal sac. Paralysis of the lacrimal pump occurs naturally in patients with facial nerve
Problem
Cause
Management
Thinning of muscle over
zygoma
Injection in a patient with high,
broad cheekbones
Inject more inferolaterally, below the
zygomatic arch
Failure of lower lid to
ascend with smile
Diffusion of botulinum toxin to
pretarsal orbicularis
If looks well, repeat! If not, inject more
laterally next time
Watery eye (epiphora)
Diffusion of botulinum toxin
towards lacrimal pump
preventing tear drainage
Avoid pretarsal orbicularis medial to
midpupillary line
Hooding
Wrinkle due to sagging skin and
not orbicularis contraction
Counsel patient carefully. Recommend
brow lift surgery or cheat with
hyaluronic acid
Large fold of wrinkles
below zygoma
(Mickey Mouse sign)
Patient has good result but poor
skin tone, causing wrinkling of
lower face only with smile
Discuss carefully
Patient may benefit from full face
resurfacing or facelift. Botulinum toxin
may be contraindicated otherwise
TABLE 8.1 n Side Effects of Botulinum Toxin Injections into the Orbicularis Oculi for Crow’s Feet
Fig. 8.7 Hypertrophic orbicularis muscle.
60
BOTULINUM TOXIN IN FACIAL REJUVENATIONImage of Fig. 8.8
Fig. 8.8 Lacrimal pump diagram.
palsy. Treatment, if indicated, is by means of a glass tube (Lester Jones tube) inserted from the
medial canthus to the nasal cavity.
Temporary paralysis of the lacrimal pump by botulinum toxin can be avoided by staying lateral
to the midpupillary line and by using low doses of high concentrations. This treatment is not
recommended for the novice practitioner.
LOWER LID BAGS (DERMATOCHALASIS AND/OR ORBITAL FAT)
Avoid injecting botulinum toxin medial to the outer orbital rim in patients with excessive lower
lid skin and fat (Fig. 8.9), because this will cause sagging of the orbicularis muscle with protrusion
of the inferior orbital fat. Remember, too, that botulinum toxin will diffuse to different degrees
in different patients.
In the author’s experience, an exception to the rule was a female smoker in her mid-40s with
marked solar elastosis. She had botulinum toxin inferolateral to her orbital rim. She developed
temporary heavy bags under both eyes as the toxin diffused towards the pretarsal orbicularis bi
laterally. Fortunately, she received only the ‘tail end’ of the diffused toxin here and the effect wore
off after a few weeks, long before the rhytids returned. It is very unusual for that level of diffusion
to occur, and her poor skin quality was a contributory factor, but be warned! The same patient
unfortunately refused to allow publication of her photographs.
8—MANAGEMENT OF CROW’S FEET
61
Discuss blepharoplasty with such patients, and demonstrate what they can expect from botu
linum toxin alone.
HOODING
Some crow’s feet will persist despite botulinum toxin. These include the skin folds at the outer
corners of the lids due either to brow ptosis or to sagging of the temporal frontalis muscle or both
(Fig. 8.10). Discuss this with the patient and suggest correct surgical treatment of these wrinkles.
Mention that ‘cheating’ with fine hyaluronic acid could also be effective (Chapter 11).
Method of Treatment
Crow’s feet may be categorised and treated accordingly, as shown in Table 8.2.
Fig. 8.10 Eyebrow ptosis.
Fig. 8.9 Lower lid ‘bags’.
Type of Crow’s Feet
Management
Wrinkles in motion
Botulinum toxin
Fine lines at rest
Botulinum toxin, collagen stimulation
Deep wrinkles at rest
Botulinum toxin, laser resurfacing, ultherapy, radiofrequency
Deep wrinkles at rest with hooding
Botulinum toxin, laser resurfacing, hyaluronic acid, brow
repositioning
TABLE 8.2 n Categories of Crow’s Feet and Their Treatment
Dose Box
BOTOX (BOTOX cosmetic): 2.5 mL dil to 100 units: 4 units 5 0.1 mL
Xeomin: 2.5 mL dil to 100 units: 4 units 5 0.1 mL
Azzalure 1 mL to 125 units (Speywood) giving 62.5 (Speywood) in 0.5 mL
Dysport 3.5 mL to 500 units (Speywood) giving 14.2 (Speywood) in 0.1 mL
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BOTULINUM TOXIN IN FACIAL REJUVENATION
Imag
e of Fig. 8.14
Fig. 8.14 Treatment of high, wide cheekbones.
Imag
e of Fig. 8.11
Fig. 8.11 Injection sites and dose for a young pa
tient with wrinkles in motion.
Imag
e of Fig. 8.13
Fig. 8.13 Deep wrinkles at rest extending over zygo
matic arch.
Once the patient has been prepared, informed, examined and photographed and has consented,
the recommended doses are as follows (shown on photographs); the reader is advised to visualise
the centre point as the centre of a circle of diffusion, as taught in Chapter 4.
n Fig. 8.11: wrinkles in motion: 0.05 mL 3 2 each side.
n Fig. 8.12: wrinkles in motion with lateral depression of brow: as previous with 0.025 mL
lateral to point of contraction. Note the brow depressors are part of the orbicularis oculi
fibres (Fig. 8.1).
n Fig. 8.13: wrinkles at rest extending over the zygomatic arch: as previous with 0.05 mL
1 cm inferolateral to lateral canthus.
n Fig. 8.14: high, wide cheekbone: 0.05 mL at outer canthus and 0.05 mL 0.5 cm below
zygomatic arch.
n Fig. 8.15: treatment of crow’s feet in older thinner skin: add in several shallow small doses
(‘bubbles’) of less than 0.0125 mL by lifting the tip of the needle to raise a bubble/bleb.
These should be placed where the wrinkles are shown to extend to as the patients smiles,
over the zygomatic arch and towards the preauricular area.
Imag
e of
Fig. 8.12
Fig. 8.12 Injection sites for wrinkles in motion and at
rest with wrinkles below lateral brow.
8—MANAGEMENT OF CROW’S FEET
63
I
mage o
f Fig.
8.1
5
Image of Fig. 8.15
Fig. 8.15 Treatment of older skin with sub cutaneous microdoses over the zygomatic arch. (A) at rest and
(B) smiling before treatment.
64
C H A P T E R 9
Botulinum toxin is widely known to be an excellent treatment for smoothing out both vertical
and horizontal forehead lines. Patients often ask for it to be used to treat their vertical (glabellar)
frown or their horizontal lines or put in a general request for improvement. It is important to find
out at an early stage whether they are looking for total immobility of the forehead (this is
often not possible—as explained below) or simply for a natural-looking effect with some residual
forehead expression and greatly reduced wrinkles.
Forehead wrinkles are due to a combination of genetic and environmental factors, especially
damage ultraviolet light. The contributions of both must be analysed when patients attend for
treatment. Make sure too that they do not expect the ablation of furrows as this requires carbon
dioxide laser resurfacing for maximum effect.
Older patients tend to develop deep forehead furrows from subconsciously lifting their
upper lid skin and brows off the eyelids. Ptosis or blepharoplasty surgery is often accompanied by
relaxation of the frontalis and elimination of such rhytids.
Botulinum toxin to the mid-forehead can lead to permanent atrophy of the muscle fibres,
with an excellent long-lasting result. This usually occurs after five or six treatments at 14-week
intervals. The glabellar muscles always seem to recover after treatment but can, with time,
diminish in size and function. Most patients continue to return for glabellar and crow’s feet
treatment, with an annual ‘top-up’ to the mid-frontalis.
Treatment of the frontalis will inevitably affect the shape of the brow. This must be assessed
carefully and discussed with the patient. The treatment of horizontal lines alone may avoid
changes to the brow, but once the glabella has been treated, the frontalis must be balanced with
the treatment.
Remember that the shape of the brow is subject to fashion. I prefer the current trend for a
female brow to have a slight arch at the junction of the medial two thirds to the lateral third. More
modern trends include a horizontal brow that elevates laterally. It is essential to avoid a ‘Dr Spock’
effect with a peak to the brow, usually achieved by the unopposed action of the frontalis on the
mid-brow, and most likely to occur when the glabellar muscles are treated independently.
Tell your patients what to expect from botulinum toxin at this stage, and discuss how their
foreheads might alter with age. Let them know that with regular treatments, they will begin to
lose their “reactive” frowning, as the central signaling area in the brain diminishes in size in
response to their Botulinum toxin treatments.
Select patients as described in Chapter 6, and take great care to avoid treating the forehead
of a patient with the rare neuromuscular disorder known as chronic progressive external
ophthalmoplegia (CPEO). Remember that such patients may not yet have been diagnosed.
Examine the eyes and eyelids of every new patient for signs of asymmetry or abnormal muscle
function. If in doubt, refer to an ophthalmologist for examination before any treatment is
attempted.
Management of Forehead
Wrinkles
9—MANAGEMENT OF FOREHEAD WRINKLES
65
Anatomy of Frown Muscles
An intimate knowledge of the anatomy of the forehead is essential for successful treatment.
There will always be a few patients with variations on the normal anatomy, but the typical
muscle attachments are shown in Fig. 9.1. In particular, note the following:
n The frontalis muscle originates from the galea aponeurosis (near the hair line) and stretches
to an insertion into the skin and the orbicularis oculi at the level of the eyebrows.
n The frontalis does not cross the midline and is separated by a central muscle-free zone at
the base of the nose (Figs 9.2 and 9.3). Movements of the galea aponeurosis unaccompa
nied by movement of the frontalis will cause wrinkling of the forehead skin, especially in
patients who can voluntarily ‘wiggle their ears’ or ‘move their scalp’.
I
mage of Fig. 9.1
Fig. 9.1 Anatomy of the forehead. The vertical fibres of the
frontalis muscle (F) insert into the skin and orbicularis oculi
at the level of the eyebrow. The frontalis muscle, innervated
by a branch of the seventh cranial nerve, originates from the
galeal aponeurosis (G). The red arrow tip is inserted below
the galea. The black arrow tip lies beneath the periosteum
of the frontal bone. Note the sensory nerve (*), a branch of
the supraorbital nerve coursing over the muscle. The fron
talis muscle usually does not cross the midline. (From Zide,
B. M., & Jelks, G. W. (1985). Surgical anatomy of the orbit.
New York: Raven Press Books, Ltd. With permission of
Barry Zide.)
I
mage of Fig. 9.2
Fig. 9.2 Note that the frontalis fibres do not cross
the midline. Note the paired frontalis muscles (F) with
their central muscle-free zone (*). The supraorbital
nerves are noted coursing upwards (small arrows).
The forceps grasp the anterior portion of the medial
canthal tendon. Note the orbicularis oculi fibres
(o), some of which originate from this tendon.
(From Zide, B. M., & Jelks, G. W. (1985). Surgical
anatomy of the orbit. New York: Raven Press Books,
Ltd. With permission of Barry Zide.)
Chronic Progressive External Ophthalmoplegia
CPEO is a rare neuromuscular disorder that causes total immobility of all the external ocular
muscles and of the levator muscles of the eyelids. Patients eventually need an operation to attach
their frontalis muscles to their eyelids (by a subcutaneous sling) so that they can open their eyes
and see. The initial presentation is often a symmetrical ptosis with brow elevation.
66
BOTULINUM TOXIN IN FACIAL REJUVENATION
n The bone at the base of the nose is covered by the procerus muscle (skin attachments only),
blending into the corrugator muscle at the level of the eyebrows, and the medial fibres of
the orbicularis oculi below the medial part of the brow.
n The corrugator muscle arises from the nasal process of the frontal bone. It is responsible for
drawing the eyebrows together, creating the vertical glabellar rhytid. The corrugator lies
deep to the frontalis, the procerus and the supraorbital nerves and arteries. It attaches to the
skin above the medial aspect of the eyebrow.
The vertical fibres of the orbicularis oculi, which run superomedial to the medial canthal
tendon, attach to the medial brow and are known as the depressor (corrugator) supercilii. The
angular veins are embedded in this muscle.
Examination of Brow/Forehead Rhytids
General appraisal
Specific glabella (vertical frown) examination
Specific forehead (horizontal frown) examination
GENERAL APPRAISAL
Brows
Hairstyle
Ptosis
Dermatochalasis
First, examine your patient carefully and decide what botulinum toxin can do for his or her
particular type of lines. Decide at this stage whether or not botulinum toxin treatment will
eliminate the wrinkles. Will laser resurfacing be needed? Will the vertical lines also require a filler
(Chapter 11)?
Eyebrows
Examine the eyebrows. Are they heavy or groomed? Some brows look as if they have descended
because of their excessive growth of hair. Simple contouring of the brow with tweezers can give
the illusion of a lift and instantly take years off the eyes (Fig. 9.4A and B). A visit to a reputable
beautician may be recommended to acquire a professional shape, which the patient can easily
maintain thereafter.Image of Fig. 9.3
Fig. 9.3 The glabella complex. (From Zide, B. M., & Jelks, G. W. (1985). Surgical anatomy of the orbit.
New York: Raven Press Books, Ltd. With permission of Barry Zide.)
9—MANAGEMENT OF FOREHEAD WRINKLES
67
Hairstyle
Discuss this with the patient. If a fringe (bangs) is being worn, will the effects of botulinum toxin be
noticeable? Is the patient happy to have botulinum toxin to prevent further ageing of the forehead,
regardless of whether or not it can be seen? Is the patient getting a receding hairline with widow’s peaks?
This can be ageing. Full forehead and scalp botulinum toxin treatment will lengthen the forehead
further. They may be advised to modify their hairstyle to hide the receding areas. Has the patient
seborrheic dermatitis, acne rosacea or psoriasis? In the author’s experience, this usually disappears in the
zones treated with botulinum toxin, to the delight of the patients. Inform them of this possible bonus.
Ptosis
Always examine the patient for signs of ptosis (a droopy eyelid). This is common in patients
over 60 years old and is usually unilateral or asymmetrical. The levator aponeurosis, which opens
the eyelid, and which is also responsible for the ‘lid crease’ by its superficial insertion into the orbi
cularis muscle and skin, slips up under the orbital rim (and eyebrow) with age or trauma, including
eye rubbing. This causes a slight drooping of the eyelid that worsens on looking down and when
the patient is tired (Fig. 9.5A and B). Patients then compensate by tensing the frontalis muscle,
Image of Fig. 9.5
Image of Fig. 9.5
Fig. 9.5 (A) Before and (B) after left levator aponeurosis reinsertion. Note high lid crease and ptosis
preoperatively.
Image of Fig. 9.4
Image of Fig. 9.4
Fig. 9.4 (A) Before and (B) after eyebrow contouring.
68
BOTULINUM TOXIN IN FACIAL REJUVENATION
developing high arched eyebrows, deep frontalis furrows and deep upper lids, which droop sleepily.
The lid crease is often noticeably higher on the affected side (normal 7 to 10 millimeters, symmetrical).
In these patients, botulinum toxin to the frontalis muscle results in an immediately obvious
ptosis (even though it was already present). Patients will also complain of the appearance of swollen
upper lids as their brow descends. The ptosis is often asymmetrical, sometimes unilateral, and
sometimes occurs in young people following trauma. It will be hard to convince these patients
that the botulinum toxin did not cause the initial ptosis. Examine carefully before treating!
Basic Ptosis Examination
n Observe the patient in the primary position (looking straight ahead).
n Measure the palpebral aperture (P.A.)—the distance from the lower lash margin to the
upper lash margin at the midpoint of the pupil.
n Place a finger over the patient’s brow to stop it from moving.
n Ask the patient to look down. Place the zero point on a fine ruler over the upper lid lashes
before immediately asking the patient to look up. Now measure the point on the ruler where
the lash margin has risen to.
n The result is the levator muscle function (normal is 15 to 18 mms).
Dermatochalasis (Eyelid Bags)
The term dermatochalasis refers to age-related wrinkling and sagging of the skin over the eyelids.
Examine carefully for brow elevation with overaction of the frontalis compensating for the ‘heavy
skin’ and subconsciously lifting it off the lids (Fig. 9.6). Botulinum treatment to the frontalis may
unmask the dermatochalasis and give the illusion of ‘swelling’ of the upper lid skin (Fig. 9.7A and B).
EXAMINATION OF THE GLABELLAR FROWN
The glabella is the area between the eyebrows. A deep rhytid, the glabellar crease, may occur in
isolation (Fig. 9.8); with a parallel but usually shorter rhytid (Fig. 9.9); or with curved rhytids under
the medial brows (Fig. 9.10). A vertical glabellar crease is usually associated with hypertrophy of the
medial corrugator fibres.
Horizontal glabellar rhytids (‘Bunny Lines’) are due both to dynamic and static factors. The
dynamic cause is contraction of the procerus muscle (there is no frontalis here). The static cause
is sagging of the forehead skin and muscle with age, overhanging the base of the nose (Fig. 9.11).
The medial fibres of the frontalis elevate the brow but overlie the brow depressor and the
corrugator. Treatment of the corrugator should avoid the brow elevator fibres.
Fig. 9.6 High raised eyebrows with forehead wrinkles and upper eyelid bags, and ‘bag’ weight induced
ptosis.
9—MANAGEMENT OF FOREHEAD WRINKLES
69
Fig. 9.11 Bunny line.
Fig. 9.10 Curved vertical frown lines.
Fig. 9.9 Parallel vertical frown lines.
Fig. 9.8 Single vertical frown in a 40-year-old woman.
Image of Fig. 9.7
Image of Fig. 9.7
Fig. 9.7 (A) Before and (B) after upper eyelid surgery for dermatochalasis, unmasked by botulinum toxin to
the forehead.
70
BOTULINUM TOXIN IN FACIAL REJUVENATION
EXAMINATION OF THE HORIZONTAL FROWN
Examine the brows carefully. First, demonstrate the effect that botulinum toxin to the forehead
would have if brow tone were to be weakened. To do this, ask the patient to close both eyes and
then to open them very slowly while looking in the mirror. This may require repeated attempts,
but show the result to the patient in the mirror (Fig. 9.12)
Examine the upper lid crease once this has been achieved. If the lid crease is unaltered by their
resting brow, then the patient is suitable for full botulinum toxin treatment. If the lid crease has
become full due to dermatochalasis or mild brow ptosis, recommend a limited botulinum toxin
treatment to the upper forehead and advise the patient that some movement of the forehead
will remain.
Brow Examination
1. Observe where the horizontal and vertical forehead rhytids lie. Are they due to excessive brow
elevation? Is the patient holding an excess of upper lid skin off their lids? Explain to the pa
tient that botulinum toxin may make them look too ‘tired’ or ‘heavy lidded’. They will be open
to a partial effect or surgical alternatives.
2. Tug on the skin below the brow to check for laxity. Does the brow droop at the sides?
Tell patients that they might get a temporary elevation of the lateral brows after treatment
(Fig. 9.13) but that this is not always repeatable as some frontalis fibres eventually atrophy.
3. Ask patients to elevate their brows. Are they symmetrical? (Most are not.) Point out any
asymmetry.
4. When the brows are elevated, do they ‘peak’ at any point? Some patients have naturally
pointed brows which, if unmasked with botulinum toxin, look unattractive (Fig. 9.14A and
B). The currently fashionable arch lies at the junction of the medial two thirds and the outer
third of the eyebrow—but fashions change.
5. Ask the patient to frown (Fig. 9.15A and B). Which fibres contract? Some patients
actually elevate their medial brow by contracting the corrugator, raising the brow superomedi
ally. Others tend to drag the brow down.
6. Decide whether or not the patient would benefit from an endoscopic brow lift or blepharo
plasties (Fig. 9.16A and B). Discuss this with them and refer if necessary. Explain the
Fig. 9.12 Ask the patient to close both eyes (allowing eyebrows to drop), then to open eyes slowly while
looking in a mirror. This demonstrates the probable resting position of the brows after botulinum toxin A to
the frontalis muscle.
9—MANAGEMENT OF FOREHEAD WRINKLES
71
Image of Fig. 9.15
Image of Fig. 9.15
Fig. 9.15 (A) Before and (B) after Botox for frowning. Patient is trying to frown in (B).
Image of Fig. 9.14
Image of Fig. 9.14
Fig. 9.14 Natural brow peaking: (A) at rest and (B) when asked to elevate brows, before receiving any
botulinum toxin treatment.
Fig. 9.13 Temporary elevation of lateral brow, creating a pleasing arch after Botox to the glabella. Note
post-laser resurfacing erythema (10 days post-laser).
72
BOTULINUM TOXIN IN FACIAL REJUVENATION
improvements possible from botulinum toxin without surgery (use your hands to stabilise the
medial brow, for example, while the patient raises the brow).
7. On the follow-up visit, before the next treatment, ask patients to place their fingers over
their brow muscles and feel the contraction as they frown. They will often notice that
the lateral fibres of the frontalis have strengthened, squeezing the corrugator toward the
glabellar area. Some patients may tolerate botulinum toxin to this lateral area, but most will
look tired, with total inaction of their frontalis if treated. Of significance is that these fibres
can strengthen with successive glabellar treatments, ‘pushing’ in the frown again despite
atrophied corrugators. The edge of a diffusion circle of treatment may be used to weaken these
fibres.
Principles of Forehead Rhytid Treatment (See Fig. 9.26)
The mid-frontalis may eventually atrophy, requiring less treatment.
The glabellar complex rarely atrophies.
Treatment changes with time as the muscle response alters.
Untreated muscle can hypertrophy with time, for example the lateral frontalis.
Treatment depends on brow position and the presence or absence of blepharochalasis.
Avoid ptosis by not injecting beneath the superior orbital rim.
Avoid peaked brows by lightly treating the frontalis 2 cm above the possible peak.
Avoid intramuscular injections close to or in the brow.
Discuss brow movement at length with the patient.
Recommended Treatment of Forehead Wrinkles
(See Tables 3.4 and 3.5)
Image of Fig. 9.16
Image of Fig. 9.16
Fig. 9.16 (A) Before and (B) after endoscopic brow lift for brow ptosis. Note that the eyebrow in (A) has
been ‘drawn in’ at a higher level than the real brow hairs, shown post operatively (arrow) in (B).
Dose Box
Botox: 2.5 mL to 100 units 5 4 units per 0.1 mL
Xeomin: 2.5 mL to 100 units 5 4 units per 0.1 mL
Dysport: 3.5 mL to 500 units 5 14.3 units per 0.1 mL
Azzalure: 0.63 mL to 125 units 5 10 units per 0.05 mL
9—MANAGEMENT OF FOREHEAD WRINKLES
73
The forehead is best treated as a single zone to achieve a balanced effect. Consider the optimal
glabellar treatment and then treat the frontalis accordingly.
Basic Glabellar Treatment (Fig. 9.17)
Treatment of a glabellar rhytid:
The essence of treatment is to paralyse the contraction of the corrugator muscle while
allowing acceptable brow movement WITHOUT descent of the medial brow or ascent of the
lateral brow! The author rarely treats the glabella alone, because most patient examinations
reveal probable diversion of signalling to the frontalis over a peaked brow. This is usually avoided
by giving 0.025 mL to the point of peaking.
Visualise diffusion circles as in Fig. 9.26. Inject 0.05 mL to 0.1 mL, depending on muscle
bulk, 1.5 to 3 cm above medial brow (line of medial canthus). ALWAYS aspirate first to avoid
the supraorbital complex. Inject 0.1 mL at the base of nose below brow level (to diffuse across
3 cm to procerus and brow depressors). Note that the procerus often resembles a pentagon when
contracted. Inject 0.025 mL 1 cm above the base of corrugator muscle, aiming not to depress the
natural brow arch.
USER TIP
Use palpation to augment observation when assessing the location of maximum muscle
contraction during frowning.
Advanced Glabellar Treatment
With experience and finesse, it is possible to inject smaller volumes of higher concentrations of
botulinum toxin. Injections can then be placed below the brow, up towards the corrugator muscle
and above the trochlear tendon towards the medial brow depressor fibres. Until then, inject al
lowing for a wider diffusion zone to avoid unwanted diffusion. Great caution must be taken not
to enter a blood vessel in the very vascular area of the superomedial orbit. Inaccurate dosage may
cause toxin to diffuse towards the levator muscle, causing ptosis, and toward the superior oblique
muscle, causing diplopia. Outstanding results may be achieved with low volumes of high concen
trations, with subtle elevation of the brows and smoothing of all furrows. However, this technique
should be undertaken only by those completely familiar with anatomical variations in this area
who are experienced enough to assess the degree of diffusion of the different concentrations ac
curately (Fig. 9.18A and B).
Ima
ge
of
Fig.
9.17
Fig. 9.17 Suggestion for glabellar treatment in inexperienced hands. Forehead complex and scalp must be
balanced to avoid peaking.
74
BOTULINUM TOXIN IN FACIAL REJUVENATION
Important Considerations for Glabellar Treatment
Injecting botulinum toxin below the orbital rim greatly increases the risks of true ptosis (a droopy
eyelid) due to diffusion of toxin towards the levator muscle of the lid.
The corrugator may be approached from below the medial brow by an expert, thereby avoid
ing the elevating frontalis fibres. Lower doses at higher concentrations are recommended—but
only in experienced hands.
The supraorbital artery, vein and nerve lie on the corrugator muscle and must be avoided.
Palpate the supraorbital notch (not always present) in the bone just medial to the medial brow.
This is the line of the supraorbital complex (2.7 cm from midline).
The angular vein traverses the area below the medial brow, the site of the depressor supercilia.
Basic Frontalis Treatment
Examine the frontalis region by asking the patient to frown repeatedly, allowing identification
of the strong points of the frontalis. Inject the bulk of the muscle adjacent to the rhytid. Inject
0.01 mL intramuscularly in the central zone as shown (Fig. 9.19) and then inject 0.05 mL to
the other areas to give symmetry. An injection of 0.025 mL subcutaneously above the mid-
lateral brow can soften rhytids whilst retaining frontalis action. On follow-up visits, inject
0.1 mL into the scalp aponeurosis to discourage hypertrophy and an overaction of aponeurotic
fibres, which would result in excessive scalp movement relative to the atrophic frontalis
muscle (Fig. 9.20).
I
m
a
g
e
of Fig. 9.18
I
m
age of Fig. 9.18
Fig. 9.18 Suggested injection sites (X) for optimal glabellar treatment in inexperienced hands. (A) Before and
(B) after frowning. Site Y is at high concentration and low volume to avoid ptosis. Do not try unless comfort
able with diffusion distances.
Imag
e of
Fig
. 9.
19
Fig. 9.19 Basic frontalis treatment.
Fig. 9.20 Injection to scalp aponeurosis.
9—MANAGEMENT OF FOREHEAD WRINKLES
75
USER TIP
Tell the patient that the treatment sites will be different each time because the muscles will
recover differently.
Different Types of Rhytids May Be Treated as Follows:
Fig. 9.21A: Simple forehead lines in motion, none at rest (20 to 30 years).
If the brows are firm, then treat the complete frontalis. Expect a semi-permanent effect within
2 years as the frontalis muscle atrophies.
Young patients with firm brow attachments are easy. Inject the glabellar area as shown in
Fig. 9.18, along the line of the corrugator. Treat the frontalis as shown to prevent peaking of the
brows. Injection sites are chosen to allow for diffusion of the toxin within 1 to 3 cm of the site.
This allows treatment of the procerus medially, sometimes incorporating some overlying frontalis
fibres with diffusion towards the brow depressor, counteracting brow depression medially at the
most nasal aspect of the brow. Fig. 9.21B shows the same patient as in Fig. 9.21A, 15 years later!
Fig. 9.22: Simple forehead lines in motion, none at rest (20 to 30 years).
Short brow lash distance with slightly mobile brows. Avoid lateral frontalis and treat supero
lateral frontalis instead. Treat medial brow depressors.
Fig. 9.23: Forehead lines at rest and in motion.
Treat as above but classify rhytids. If severe, advise about CO2 resurfacing.
I
m
a
g
e
of Fig. 9.22
Fig. 9.22 Wrinkles in motion with suggested injection sites (X) in a 20-year-old woman with short lash-brow
distance and mobile brows.
Image of Fig. 9.21
Image of Fig. 9.21
Fig. 9.21 (A) Before simple forehead lines in motion, none at rest (20 to 30 years), and (B) after treatment,
15 years later.
76
BOTULINUM TOXIN IN FACIAL REJUVENATION
Fig. 9.24: High arched brows with furrowed horizontal lines in patient over 35.
Take great care. This patient is typical of those who can become extremely distressed if they
lose the deep appearance of their upper eyelids as the frontalis becomes paralysed with botulinum
toxin. The heavy brow can sometimes weigh upon the upper lid simulating ptosis; but when the
brow is gently lifted by the examiner’s finger, the lid will return to its normal position.
Discuss surgical correction at length (Chapter 11). Consider botulinum toxin treatment to
the upper rhytids, retaining the elevating action of the lower frontalis fibres. Offer filler to the
glabellar crease and the fine lines over the lateral brow.
Fig. 9.25: The male forehead.
The male brow tends to be horizontal with a short lash brow distance. The muscles may be
bulkier than those of the female forehead and sometimes need greater doses. Treatment of the
glabellar area per se can lead to a feminising arch and must be avoided unless requested. The male
forehead is also prone to a receding hairline. Such patients may require extensive volumes of
botulinum toxin to treat the occipito-frontal portion of the frontalis; otherwise, they will return
with frontal furrows.
Image
of
Fig. 9.24
Fig. 9.24 Suggested doses and injection sites in a patient over 35 with high arched brows and wrinkled
forehead. Retain brow height, if desired, by avoiding botulinum toxin to brow area (i.e. lower half of forehead).
Ima
ge
of
Fig.
9.2
3
Fig. 9.23 Suggested injection sites with suggested doses in a patient over 40 with high arched brows and
wrinkled forehead, note the sites are NOT symmetrical, in keeping with the asymmetrical frontalis mass.
9—MANAGEMENT OF FOREHEAD WRINKLES
77
Fig. 9.25 Typical heavy male forehead.
Image of
Fig. 9.26
Fig. 9.26 Low heavy brows. Note the signal to raise brows is equal across the forehead (green rays overhead)
before treatment. The pink circles of diffusion are used to overlap the corrugator (blue) and the procerus (grey
pentagon) and the brow depressors (pale green stripes). Note the space between the circles (pale green stripes
on forehead) are left to allow lift and shape.
78
C H A P T E R 10
Treatment of the Perioral
Region, the Neck and Scars
A good knowledge of the anatomy of the perioral region is essential before undertaking
botulinum toxin treatment. The orbicularis oris responds well to botulinum toxin, but great care
must be taken to limit diffusion into the surrounding muscles (Fig. 10.1). This can be achieved
by using a higher concentration of the toxin, at a smaller dose. Treatment of the wrong muscle
fibres can lead to dribbling, difficulty in drinking water, slurred speech and asymmetrical smiling.
Patients with facial hemispasm frequently require botulinum toxin to a focus of spasm over
the elevator of the lip. This leads to a depression of the corner of the mouth and drooling of saliva
(Fig. 10.2). But patients would usually rather have an embarrassing dribble than an uncomfort
able spasm and twitching of the side of their face. However, this complication MUST be avoided
in a cosmetic practice.
Ageing of the Perioral Region and Neck
Ablating wrinkles does not always make a patient look younger. When considering rejuvenation
of this area, examine the overall tone of the musculocutaneous complex. Also examine the skel
etal support, the dentition and the shape of the nose.
Research has confirmed that ageing causes an anteropostero recession of the facial bones,
which contributes to sagging. The distance from the nose to the vermilion border increases with
time. The vermilion border itself shrinks, and the lips lose volume and tend to turn downwards
instead of up and out.
The lip depressors and elevators induce wrinkles at the corners of the mouth and ‘marionette
lines’. The mentalis muscle encourages the tip of the chin to turn upwards, creating the mental
fold and sometimes a ‘pointed’ chin. Recession of the jaw will accentuate the wrinkles, from the
corner of the mouth to the chin.
The platysma muscle will eventually draw the sides of the mouth towards the jaw, and this,
along with facial sagging, creates jowls. Increased resting tone of the platysma creates vertical
bands (turkey neck) along the line of action and ‘venus rings’, that is horizontal banding, perpen
dicular to the line of action.
The tip of the nose becomes pulled down with time (pointed nose) and the descent of the
midface, coupled with recession of the facial bones, deepens the nasolabial folds.
Dose Box (see Tables 3.4 and 3.5)
BOTOX 2.5 mL to 100 units, 4 units in 0.1 mL
Xeomin 2.5 mL to 100 units, 4 units in 0.1 mL
Dysport 3.5 mL to 500 Speywood units, 14.3 units in 0.1 mL
Azzalure 0.63 mL to 125 Speywood units, 10 units in 0.05 mL
10—TREATMENT OF THE PERIORAL REGION, THE NECK AND SCARS
79
Treatment
Botulinum toxin causes a flaccid paralysis of muscles that have been injected and so induces
a mild elongation as the muscle spindles stop contracting. This is particularly obvious in the
vertical muscles of the face, for example in the upper lip. Almost all patients may successfully
have their upper lip rhytids replaced with fresh smooth skin using CO2 resurfacing, at different
intensities and depths. Examine the patient carefully and consider the likely effect of elongating
Fig. 10.2 Mouth droop following botulinum toxin for severe blepharospasm.
Image of
Fig. 10.
1
Fig. 10.1 Anatomy of the perioral area. (From Zide, B. M., & Jelks, G. W. (1985). Surgical anatomy of the
orbit. New York: Raven Press Books, Ltd. With permission of Barry M Zide.)
80
BOTULINUM TOXIN IN FACIAL REJUVENATION
a perioral muscle before injecting it. If the patient already has a long nasal-vermilion distance,
for example (Fig. 10.3A and B), then treating upper lip wrinkles with further relaxation of
the muscle will not produce a good appearance. Treatment of the nasolabial fold will also
lengthen the upper lip. These patients can be offered alternative treatments such as surgery, CO2
resurfacing and fillers (Fig. 10.4A and B) (see Chapter 11).
Perioral Indications
Upper lip rhytids
Lower lip rhytids
Pebbly chin
Elevation of lip corner
Reduction of nasolabial folds
Image of Fig. 10.4
Image of Fig. 10.4
Fig. 10.4 CO2 laser elimination of perioral rhytids, before (A) and after (B).
Image of Fig. 10.3
Image of Fig. 10.3
Fig. 10.3 (A) Before and (B) 1 week after first CO2 laser treatment to shorten upper lip and soften deep rhytids.
10—TREATMENT OF THE PERIORAL REGION, THE NECK AND SCARS
81
USER TIP
Study the anatomy of the mouth and muscles affecting the lips carefully before treating this
area.
UPPER LIP RHYTIDS
The author tries to avoid use of botulinum toxin to the upper lip unless absolutely essential. Some
patients have small convex maxillae and are more prone to excessive resting tone of their orbicularis
oris in the upper lip. Moderate rhytids, particularly in nonsmokers, can sometimes be discouraged with
a small volume of botulinum toxin injected away from the vermilion border (Fig. 10.5). Limiting the
contraction of the orbicularis oris will always curtail its true function as a sphincter around the mouth
for articulation and eating. Patients often notice a weakening of their ability to ‘pout’ and, even though
they seldom actually slur their speech, they sometimes experience the sensation of slurring.
More profound side effects occasionally occur, and patients must be warned about these.
Milder sensations of poor articulation often wear off over the first few weeks. It is often easiest
to counteract the risks by using a milder phased treatment augmented with resurfacing or fillers.
Whenever possible, encourage CO2 resurfacing of the rhytids for at least a 50% long-term
improvement (Chapter 11), or, if an instant remedy is desired, inject hyaluronic acid into the
valley of the rhytid. Some patients benefit from both; but the author never recommends both at
the same time in the lip or nasolabial fold area, to avoid inadvertent oedematous diffusion of the
botulinum toxin.
If necessary, no more than 0.0125 mL of botulinum toxin per site (at the above dilutions) is
recommended, subcutaneously. Using a lower volume at a higher concentration is also valuable,
but difficult to manipulate at first and is perhaps best tried by an experienced operator.
USER TIP
Avoid injecting fillers and botulinum toxin into the perioral area at the same time. Botulinum
toxin can elongate and flatten the lip, requiring a different level of filler. The filler may also
appear as nodules if given to an area which subsequently flattens with botulinum toxin.
USER TIP
It is sometimes safer to treat deep upper lip rhytids with laser resurfacing and/or injections of
hyaluronic acid than with botulinum toxin, because of the twin risks of weakening the lip
sphincter and elongating the lip (Chapter 11).
Fig. 10.5 Botulinum toxin (0.02 mL) to a superolateral rhytid in upper lip.
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BOTULINUM TOXIN IN FACIAL REJUVENATION
VERMILION BORDER
Fine ‘bleeder’ lines at the vermillion border can be injected with 0.0125 mL of botulinum toxin
(Fig. 10.6). Avoid injecting rhytids farther away from the vermillion border at the same time.
This minimises the laxity of the lip and the risk of side effects. Injections can be intramuscular
or subcutaneous, depending on the patient.
Corner of Mouth
Botulinum toxin to the depressor of the angle of the mouth, just above the lower border of the face,
1 cm lateral to the angle of the mouth, can achieve a sought-after upturn of the outer corners,
which can be nicely augmented with hyaluronic acid (Fig. 10.7). The depressor anguli oris is
intimately associated with the underlying platysma and the adjacent depressor labii inferioris.
Unwanted diffusion to the depressor labii inferioris will result in an inability to purse the lower lip,
asymmetry when smiling, and even dribbling when drinking. Some experts recommend avoiding
these side effects by injecting subcutaneously and not within 1 cm of the angle. Hyaluronic acid
inferolateral to the lateral oral commissures, sometimes with some inside the lower and upper lip
bordering the commissure, can often give a superior result to botulinum toxin here.
USER TIP
For perioral treatment, if in doubt, start with a low dose and low dilution of botulinum toxin,
given subcutaneously. Review the patient within 2 weeks and give more if necessary.
Fig. 10.7 Filler to lateral commissure.
Fig. 10.6 Filler to vermilion border to treat ‘bleeder lines’.
10—TREATMENT OF THE PERIORAL REGION, THE NECK AND SCARS
83
NASOLABIAL FOLDS
Injections of botulinum toxin have been used to treat deep nasolabial folds, but the loss of tone
in the midface is better managed with volume replacement. The larger particle size, for example
Perlane, works well here, especially if initially layered on the superolateral aspects of the face
(lateral zygoma, temporal fossae), creating a restorative ‘lift’, reducing the nasolabial folds and
avoiding unnatural anterior facial volume changes (Chapter 11).
PEBBLY CHIN AND MENTAL CREASE
Botulinum toxin is excellent for smoothing the mentalis muscle, the main muscle responsible for
wrinkling of the chin (Fig. 10.8). It is important to warn patients that the result may be asym
metrical at first, as the toxin may diffuse more towards one head of the muscle. Start with a low
dose (0.025 mL) and increase this until the desired effect is achieved. Insert the needle directly
below the centre of the tip of the chin, withdraw slightly having reached the periosteum, and
inject 0.025 mL initially. Consider subsequent subcutaneous injections of 0.0125 mL to the
overlying depressor anguli oris.
The mental crease deepens with age as the tip of the chin elevates (a ‘Wicked Witch’ chin).
Hyaluronic acid (especially Perlane) will fill it instantly (Fig. 10.9).
Botulinum Toxin to the Neck
Botulinum toxin is very effective at neutralising the pull of the platysma muscle under the chin
and so preventing horizontal banding lower down on the neck (Fig. 10.10). The author gives it
to most patients with facial palsy to minimise the unilateral platysma band they usually develop
(Fig. 10.11A and B). It is also effective in the treatment of ‘turkey neck’—the vertical folds of
platysma lying between the mandible and the clavicle. It is particularly good in combination with
ultrasound, radiofrequency and CO2 collagen stimulation treatments of the region.
The platysma spreads out from its origin at the base of the mandible and parotid fascia, down
the neck and along the pectoral fascia. A reduction in the pull of the platysma tends to give the
illusion of elevating the lower facial muscles and, in some patients, even of a reduction in their
marionette folds. Treatment to the jowls (0.05 mL) and platysma bands sharpens the jawline and
is known as the ‘Nefertiti’ lift.
Care must be taken to prevent diffusion of the toxin towards the oesophagus, which is
extremely sensitive to it, as there have been several reports of unexpected dysphagia from earlier
Fig. 10.9 Melomental fold.
Fig. 10.8 Example of a pebbly chin before botulinum
toxin treatment.
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BOTULINUM TOXIN IN FACIAL REJUVENATION
treatments, using doses similar to the frontalis ones. Care must also be taken to avoid the larynx
as hoarseness has also been reported, along with difficulty in lifting the head. Divide the promi
nent area visually into units, and aim to space the injections of 0.05 mL 1.5 cm apart. Treat
only the ‘band’ that is obvious at rest sitting upright, and not the flat part of the platysma that
protrudes on effort. Treatment of the band often suffices and reduces the volume of botulinum
toxin required (Fig. 10.12).
Finally, remember that some patients with prominent neck banding and ‘jowls’ would benefit
from a lower facelift. Always discuss this surgical option with them and then refer them to a
plastic surgeon.
Botulinum Toxin for Scars
Patients who normally heal well in other parts of their face tend to heal badly if they have a
linear scar perpendicular to the direction of pull of a facial muscle. Muscle pull stretches and thins
scars, which often remain red. This is particularly true for the frontalis muscle. The muscle can
also pucker and ‘dip’, particularly in the perioral region and when parallel to the muscle action.
The traditional way of correcting unsightly forehead scars has been to re-excise them, taping
the incision firmly with Steri-Strips and then bandaging the forehead for up to 6 weeks in an
effort to keep tension off the margins of the scar. Botulinum toxin will provide a tension-free
zone for up to 14 weeks (sometimes longer in the frontalis area).
Image of Fig. 10.11
Image of Fig. 10.11
Fig. 10.11 Before (A) and after (B) botulinum toxin to neck in patient with facial palsy.
Fig. 10.10 Treatment of horizontal neck banding with 0.05 mL per site. The skin must be held
between the fingers whilst injecting to avoid diffusion to the larynx or oesophagus.
10—TREATMENT OF THE PERIORAL REGION, THE NECK AND SCARS
85
FRONTALIS SCARS
Inject the frontalis muscle evenly across the whole forehead, as in the treatment of rhytids
(Fig. 10.13A) .This keeps tension off the scar while preventing asymmetry of the forehead, which
would occur with injections localised to the scar itself. Make sure that every centimetre along the
scar receives botulinum toxin, giving 0.5 cm on either side of the scar. The dose per site used is
0.05 mL.
PERIORAL SCARS
Great care must be taken to avoid the toxin diffusing towards the lip elevators or sphincter muscles of
the mouth. Begin with the lowest dose, and increase this until an effect is achieved. Review the patient
after 10 to 14 days to decide on this. Fig. 10.14A and B shows a scar that followed a road traffic
accident in a patient who requested laser resurfacing. Examination showed that the scar was much
I
m
a
g
e
o
f Fig. 10.13
Fig. 10.13 Scar on forehead prior to excision, showing recommended sites for botulinum toxin before
surgery. 0.05 mL at ‘x’.
Fig. 10.12 Injection mark on neck of patient following vertical neck band treatment.
86
BOTULINUM TOXIN IN FACIAL REJUVENATION
more unsightly ‘in motion’, that is while the patient was talking, than ‘at rest’. BOTOX 0.0125 mL
was therefore injected on either side of the scar, at sites 1 cm apart. The scar appeared to flatten over
the next week and the patient was extremely happy. Follow-up treatment with the same dose, 14 weeks
later, gave the patient the feeling of a ‘drag’ on that side of her mouth. This could not be detected on
examination, but the botulinum treatment schedule was modified to annual sessions with occasional
injections of hyaluronic acid as required (Chapter 11).
Décolleté
Multiple low concentrations of dilute subcutaneous injections in a ‘v’ shape to the décolleté
reduce the sagging and accelerate remodelling with collagen-stimulating CO2 resurfacing,
radiofrequency and ultrasound treatments.
I
m
age of Fig. 10.14
Image of Fig. 10.14
Fig. 10.14 Before (A) and after (B) botulinum toxin to scar on chin. ‘x’ 5 0.125 mL.
87
C H A P T E R 11
Other Solutions
Hyaluronic acid
Laser resurfacing
Upper and lower blepharoplasty
Combination treatments
Brow lift, neck lift, suborbicularis oculi fat lift
Fat transfer and nanofat injections
Collagen stimulating combination treatments
Dermaroller
Platelet rich plasma
Ultherapy ultrasound/radiofrequency
Skin protection and rejuvenation products
Introduction
Botulinum toxin is good at preventing wrinkles in certain age groups. It is the ideal treatment
for ‘wrinkles in motion’ (dynamic lines) and can even dissolve ‘wrinkles at rest’ (static lines) in
patients with good skin tone (see Fig. 8.2A and B). However, patients with poor skin tone, and deep
crow’s feet at rest, will not get a good response from botulinum toxin alone (Fig. 11.1A and B).
Those with furrowed brows but a low lash-brow distance, poor tone of their forehead skin and/or
an excess of upper lid skin (dermatochalasis) will actually look worse if they lose further muscle
tone after botulinum toxin. They need an alternative treatment.
Ageing skin sags for several reasons. The skin loses collagen, becoming thinner and less trans
parent as the parallel collagen fibres become cross-linked and misaligned. This is greatly acceler
ated by smoking and exposure to ultraviolet (UV) A and B rays. The time at which ageing starts
is genetically predetermined: if a mother does not have a wrinkle until the age of 55, then her
Image of Fig. 11.1
Image of Fig. 11.1
Fig. 11.1 Pre- (A) and post- (B) CO2 resurfacing and botulinum toxin to static crow’s feet rhytids.
88
BOTULINUM TOXIN IN FACIAL REJUVENATION
daughter with the same genes and habits may not either. Clearly, the extent to which the skin
ages also depends upon environmental factors. If a mother has had an excessive exposure to the
sun and smokes, when she does begin to age at 55, she will probably become severely wrinkled
within a short time. On the other hand, if her daughter—with the same genes—avoids UV dam
age and smoking, she may well retain the tone in her skin for much longer.
It is sensible to educate all botulinum toxin patients on the subject of skin protection
and recovery (‘stopping the clock’). Aesthetic nurse practitioners may spend time assessing the
patients’ skin regime and, if necessary, tretinoin (the author campaigns against cancer-causing
paraben preservative in creams, etc.), paraben free, can be prescribed.
Ageing of the face is also due to the recession of its skeletal support. The anteroposterior
diameter of the skull lessens with time, and this encourages sagging in spite of an otherwise
excellent skin tone. The diameter of the orbit increases from superomedially to inferolaterally,
reducing support for the orbicularis oculi muscles and skin. Traditional cosmetic surgery
replaces this lost support by excising skin and muscle (facelift, blepharoplasty). Facial
implants, such as malar and chin implants, have been used. The author favours the natural
reinforcement of the foundations of the face with autologous fat transplant, using nanofat
for the periocular tissues. Laser resurfacing can tighten and ‘lift’ sagging structures. Brow lifts
are being replaced by brow repositioning (internal brow fixation or an endoscopic brow lift),
while blepharoplasties often include lateral canthal tendon plication to tighten the sagging
areas over an expanded orbital rim.
The tone of the skin is actively enhanced with collagen-stimulating treatments such as dermarol
ling and serum plasma injections. Autologous fat brings stem cells and plasma factors with it, further
nourishing and rejuvenating ageing skin. Hyaluronic acid fillers are used to finesse periocular volume
replacement, as well as supplementing lost skeletal support with larger molecule fillers such as Perlane.
The ways in which patients should be selected for botulinum toxin are discussed in detail in
earlier chapters. Some alternatives (see Table 11.1) are discussed here.
Hyaluronic Acid and Other Fillers
‘Fillers’ are volume-replacing products that can be inserted with a cannula or injected into the
skin. The principle behind their use is that, with age and sun damage, the face loses volume and
so the skin sags.
Indication
Treatment
Crow’s feet at rest
Laser resurfacing, platelet rich plasma, radiofrequency Viora
Reaction, hyaluronic acid skin boosters
Lower lid bags
Laser blepharoplasty, fat transplant, nanofat remodelling
Vertical frown with low lash brow distance
Endoscopic brow lift, hyaluronic acid
Frown with heavy upper lid skin
Upper lid blepharoplasties, brow repositioning, hyaluronic acid
Upper lip rhytids, mouth zone rhytids
Laser resurfacing, PRP, Dermaroller, radiofrequency Viora
Reaction, hyaluronic acid
Platysma bands, neck rhytids
Lower facelift,
Threads, Viora radiofrequency, PRP, skin boosters,
Dermaroller.
Poor skin tone, sun damage
Restylane skin boosters, PRP, Viora radiofrequency,
Dermaroller. Microdermabrasion, chemical peels,
tretinoin, alphahydroxy acid skin regime, vitamins C
and E serum, sun protection
TABLE 11.1 n Indications for Alternative Treatments with or Without Botulinum Toxin