Altering brow contour with botulinum toxin

Lifting effect of onabotulinumtoxinA in patients treated for glabellar and crow's feet rhytids

OnabotulinumtoxinA injection can enhance the appearance of the eyes. This study evaluated the lifting effect of onabotulinumtoxinA treatment of the eye area. A retrospective, single-center audit of patients treated for glabellar and crow's feet rhytids was undertaken. Standardized photographs taken before and 2-4 weeks after treatment were assessed. Computer-based measurements were made of the height of the visible superior tarsal plate (STP) and brow (measured from upper eyelid lash edge to eyebrow base) at rest and maximum frown. One hundred patients were included (96 females; mean age: 46.2 ± 8.8 years). Mean onabotulinumtoxinA doses were 14.95 ± 0.61 units (glabella) and 17.83 ± 2.74 units (crow's feet). There were significant post-treatment increases in mean STP height at rest (left side, 0.76 ± 0.99 mm, p = .02; right side, 0.79 ± 0.94 mm, p = .01) and maximum frown (left, 2.25 ± 1.52 mm, p < .0001; right, 1.87 ± 1.34 mm, p < .0001), and mean brow height at rest (left side, 1.54 ± 1.49 mm, p = .0006; right side, 1.47 ± 1.84 mm, p = .0009) and maximum frown (left, 4.37 ± 2.29 mm, p < .0001; right, 4.16 ± 1.88 mm, p < .0001). OnabotulinumtoxinA injection is effective for elevating brow position and increasing STP show.

Botulinum Toxin Application in Facial Esthetics and Recent Treatment Indications (2013-2018)

Background

Ever-changing perception of beauty from childhood to old age is changing with the revolution in cosmeceuticals science. Esthetics is an individual's perception since time immemorial. Standards of beauty have changed through centuries with increased awareness about esthetics. The face remains main source of information for identification and discrimination. It constitutes a structural ground for many nonverbal messages including the emotional state of a person, so the proverb "Face is an index of mind" holds good. The wrinkles and laxity are considered to be one of the factors for aging. Hence, escalating demand for cosmetic treatment to reduce facial wrinkles and laxity has stimulated us to search for published literature for nonsurgical techniques for enhancement of facial beauty. The review analyzed the published data to provide narrative basic review in a concise way to the beginners, clinicians, and students.

Materials and Methods

We have adopted search criteria using keywords: Botox, Botulinum toxin, incobotulinumtoxinA, esthetics, face, uses of Botox, with various Boolean operators and or in title, and abstract using PubMed search engine. The database search limited to PubMed only from January 2013 to June 2018.

Results

Various search results have been appended as annexures at the end of the article for further reference for the readers. Finally, 17 references were selected to write narrative review to meet our objectives.

Conclusion

The advancing front in the use of toxins is an emerging science for the beautification of a face. Botox exploded in to market because of efficacy, tolerability, and minimally invasive nature. The present review gives brief about the history of Botulinum toxin, types, mechanism of action, clinical indications, preparations, storage, and technique for various uses with a brief note on patient selection, contraindications, and complications.

Botulinum Toxin for Eyebrow Shaping: A Systematic Review

BACKGROUND

Currently, there is no standardized approach for eyebrow shaping with botulinum toxin, and controversies still exist regarding this subject.

OBJECTIVE

The objective of this systematic review is to summarize and compare all the published data regarding eyebrow shaping with botulinum toxin.

METHODS

On March 10, 2017, an online search of published articles in the Medline, Embase, and Cochrane databases were conducted. All articles that used objective measurements to quantify the eyebrow changes after botulinum toxin injection were included in this review.

RESULTS

Eleven studies were selected for inclusion with a total of 585 patients. All the included studies used onabotulinumtoxin A. Seven studies injected both the lateral and the medial eyebrow depressors, 2 studies injected the lateral depressors alone, and 2 studies injected the medial depressors alone. The highest elevation was observed in the lateral brow (0.4-4.8 mm). Bruising and headache were the most frequently reported complications, and only 5 cases of eyelid ptosis were noted.

CONCLUSION

Botulinum toxin injection for eyebrow shaping is a noninvasive, safe, and reproducible procedure. Eyebrow reshaping can be achieved by targeting different muscle groups. However, further randomized controlled trials are warranted.

Aesthetic uses of the botulinum toxin

The cosmetic use of botulinum toxin (BoNT) is the most common cosmetic procedure performed in the world today. Common adverse events seen in the aesthetic use of the BoNT include swelling, localized bruising, headaches, injection site discomfort, excessive muscle weakness, and unintended paresis of adjacent muscles. BoNT has a wide array of cosmetic uses, including treatment of glabellar lines, chemical browlift, forehead wrinkles, periorbital, and perioral lines. The future formulations and applications of BoNT type A will be plentiful, and are exciting to consider.

Advances in minimally invasive facial rejuvenation

PURPOSE OF REVIEW

Current cosmetic surgical practice for facial rejuvenation has undergone a significant change due to the introduction of technologies to improve the age-associated changes of the face. The most widely adopted methods of minimally invasive facial rejuvenation include the use of neuromuscular blocking agents and injectable fillers. The topic of minimally invasive procedures might include a variety of subjects including nutritional and hormonal modulation, light-based and laser-based therapies, minimal incision surgical procedures, as well as the use of botulinum toxin and fillers. The focus of this study will be on the minimally invasive facial rejuvenation efforts achieved by injection techniques.

RECENT FINDINGS

Botulinum A neurotoxin has been shown to be effective in the reduction of hyperfunctional lines in the upper and lower face. Anatomic areas that have been found to benefit include the glabella, the forehead, the periorbital area, lips, and the platysma muscle. The more recently introduced hyaluronic acid and other injectable fillers are receiving increasing usage. These temporary fillers have been found to improve creases and wrinkles, augment deep nasolabial folds, augment thin lips, and improve hollowing in the periorbital and other depressions and deformities.

SUMMARY

There has been a significant paradigm shift in the field of rejuvenation surgery. Injectable minimally invasive methods have been offered to remedy age-related and other acquired deformities of the head and neck region. These methods have provided temporary correction of undesirable characteristic that were traditionally approached with more invasive surgically oriented modalities.

Primary and Adjunctive Uses of Botulinum Toxin Type A in the Periorbital Region

Chemodenervation with botulinum toxin has become an integral part of the facial plastic armamentarium. Although eyebrow and eyelid cosmetic deformities and asymmetries have traditionally been treated by surgical intervention, Botox can now be incorporated effectively into the surgical plan. When the surgeon has a complete understanding of facial anatomy and muscular interactions, Botox can be used as a primary treatment of the periorbital region or as an adjunct to surgical procedures of the periorbital region.

Botulinum Toxin in Ophthalmology

Since its introduction into clinical medicine in 1980, botulinum toxin has become a major therapeutic drug with applications valuable to many medical sub-specialties. Its use was spearheaded in ophthalmology where its potential applications have expanded to cover a broad range of visually related disorders. These include dystonic movement disorders, strabismus, nystagmus, headache syndromes such as migraine, lacrimal hypersecretion syndromes, eyelid retraction, spastic entropion, compressive optic neuropathy, and, more recently, periorbital aesthetic uses. Botulinum toxin is a potent neurotoxin that blocks the release of acetylcholine at the neuromuscular junction of cholinergic nerves. When used appropriately it will weaken the force of muscular contraction, or inhibit glandular secretion. Recovery occurs over 3 to 4 months from nerve terminal sprouting and regeneration of inactivated proteins necessary for degranualtion of acetylcholine vesicles. Complications are related to chemodenervation of adjacent muscle groups, injection technique, and immunological mechanisms.

Eyebrow Height after Botulinum Toxin Type A to the Glabella

INTRODUCTION

Botulinum toxin type A (BTX-A) has demonstrated impressive safety and efficacy for the treatment of dynamic facial rhytides, particularly in the upper face. Numerous reports have cited an associated brow lift with BTX-A injections in the glabellar complex, presumably caused by deactivation of the brow depressor muscles. Few analyses examining this phenomenon more closely exist, however.

OBJECTIVE

The objective was to examine objective changes in eyebrow and eyelid height following BTX-A treatment for glabellar rhytides.

METHODS

A retrospective analysis of subjects' photographs taken during a single-center, dose-ranging, parallel-group, double-blind, randomized trial with 1-year follow-up in which women with moderate-to-severe wrinkles at maximum frown received a total of 10, 20, 30, or 40 U BTX-A in seven sites in the glabella alone. Photographs of the eyes and forehead region were taken in repose at baseline and every 2 weeks after treatment for up to 20 weeks. Eyebrow height was measured at midpupillary line ("a"), outer edge ("b"), and medial canthus ("c"). Changes in eyebrow height between baseline and after treatment were recorded for each subject. Brow lift was considered successful if measurements "a" and "b" increased after treatment.

RESULTS

A total of 79 women were assessed. Central injections of 20 to 40 U BTX-A into the glabella alone (with the most lateral injection at the midpupillary line) led to an immediate lateral eyebrow elevation, followed by a central and medial eyebrow elevation that peaked at 12 weeks after treatment. The lowest dose of BTX-A (10 U) produced an initial mild brow ptosis and the weakest response.

CONCLUSION

Doses of 20 to 40 U BTX-A produced dramatic changes in eyebrow position that may be due to diffusion of BTX-A into and partial inactivation of the medial fibers of the frontalis, with resulting increased muscle tone in the lateral and superior muscle fibers of the frontalis.

Management of the ageing eyebrow and forehead: an objective dose-response study with botulinum toxin

OBJECTIVE

To determine if clinical use of two different doses of botulinum exotoxin A (BTX-A) injections to the forehead area result in wrinkle reduction and modifications of eyebrow position.

DESIGN

Prospective study.

SETTING

Private practice, Dermatologic Laser Centre, Marseille, France.

SUBJECTS

Twenty-four adult patients treated with BTX-A (Vistabel) injections for forehead rhytides.

INTERVENTION

Of the 24 patients, 12 received BTX-A injections of 5 U only and 12 received injections of 10 U into the forehead, with or without treatment of the lateral forehead. The eyebrow position, forehead height and number of forehead lines determine the number of injection points. Patients were evaluated before injection and every 2 months after treatment during next 8 months.

RESULTS

In the two groups of 12 patients, we found no significant change between the two doses. At each time after injections (every 2 months until 8 months), both groups showed a statistically significant improvement except at 8 months. Both groups exhibited the same results on standardized photos and on 3D skin profilometry.

CONCLUSIONS

The two doses of BTX-A injections into the forehead gave the same results. The duration of the effect is similar along 8 months. This study emphasizes the role of low doses of BTX-A injections to obtain good clinical results without freezing aspect.

Primary and Adjunctive Uses of Botulinum Toxin Type A in the Periorbital Region

Chemodenervation with botulinum toxin has become an integral part of the facial plastic armamentarium. Although eyebrow and eyelid cosmetic deformities and asymmetries have traditionally been treated by surgical intervention, Botox can now be incorporated effectively into the treatment plan. When the surgeon has a complete understanding of facial anatomy and muscular interactions, Botox can be used as a primary treatment of the periorbital region or as an adjunct to surgical procedures of the periorbital region.

The male eyebrow: a topographic anatomic analysis

PURPOSE

To study and quantify the topographic anatomy of the male eyebrow and its 3-dimensional relation, based on age and location, relative to the eye and the supraorbital rim.

METHODS

A prospective cohort of male patients seen for routine ophthalmic evaluation age 10 years and older had several eyebrow measurements incorporated in the examination. The presence or absence of brow ptosis was noted on the basis of observation. The location of the eyebrow relative to the center of the pupil, the lateral canthus, and the depth of the supraorbital rim was measured. The data were subjected to statistical analysis.

RESULTS

The study included 444 eyebrows of 222 patients ranging in age from 10 to 86 years, with a mean age of 46.75 years. The incidence of brow ptosis was 7.4%. The mean distance between the lateral canthus and inferior brow (LIBD) was 11.23 mm. The mean distance between the pupil and the inferior brow and the superior brow border was 11.15 mm (PIBD) and 19.8 mm (PSBD), respectively. Statistical analysis demonstrated that the mean brow position did not vary with age. However, there was a significant negative correlation between the position of the eyebrow and the depth of the superior sulcus below the supraorbital rim (correlation coefficient, 0.431 for PIBD and depth and 0.381 for LIBD and depth, respectively). Deeper-set eyes had lower brow position.

CONCLUSIONS

The male eyebrow sits along the supraorbital ridge and has a flat contour. In men without frank brow ptosis, the eyebrow position relative to the pupil and the lateral canthus does not significantly fall with age despite the periocular changes associated with aging. However, 3-dimensional analysis demonstrates that individuals with deep-set eyes have a lower positioned eyebrow then those with a more shallow depth below the supraorbital rim. These findings are helpful in surgical management of the eyelid-eyebrow continuum. The age-related changes in the eyebrow area should be thought of as a 3-dimensional construct with collapse of the structure and not simply descent of the eyebrow.