Browlift with botulinum toxin

Impact of Glabellar Injection Technique With DaxibotulinumtoxinA for Injection on Brow Position

BACKGROUND

Precise injection technique is vital for avoiding suboptimal eyebrow position when treating glabellar lines with botulinum toxin type A.

OBJECTIVES

The aim of this study was to evaluate the impact of glabellar injection technique on eyebrow position in patients treated with DaxibotulinumtoxinA for Injection (DAXI).

METHODS

This retrospective post hoc analysis involved 60 adults who received a single treatment with DAXI 40 U to the glabella and had standardized facial photography. Median vertical and horizontal displacement of the brows (at rest) at baseline and 2 weeks after glabellar injection were measured. Brow position outcomes were evaluated by an oculoplastic surgeon and expert anatomist. Investigators were interviewed to ascertain individual injection techniques.

RESULTS

Precise injection location and depth, and median resting brow position following treatment varied between investigators. Positive brow outcomes were achieved with deep DAXI injections into the medial corrugator, superficial lateral corrugator injections placed between the midpupil and lateral limbus, and deep midline procerus injections. Glabellar injection technique that more precisely targeted the corrugator muscles resulted in longer glabellar line treatment duration compared to a less targeted technique. Medial corrugator injections above the medial brow; lateral corrugator injections administered deeply or more medially, toward the medial third of the brow; and procerus injections superior to the inferomedial brow tended to be associated with suboptimal outcomes that were more apparent during dynamic expression.

CONCLUSIONS

Aesthetically pleasing brow outcomes and greater duration of efficacy can be achieved with an injection pattern that precisely treats the anatomic location of the corrugator supercilii and procerus muscles, avoiding the frontalis.

LEVEL OF EVIDENCE: 4

Impact of DaxibotulinumtoxinA for Injection on Brow Position and Frontalis Muscle Activity Following Treatment of Glabellar Lines

BACKGROUND

Botulinum toxin type A (BoNTA) injections for the treatment of facial lines may lead to pleasant or undesirable changes in eyebrow height and position.

OBJECTIVES

The aim of this study was to evaluate the impact of glabellar injection of DaxibotulinumtoxinA for Injection (DAXI), a novel BoNTA formulation, on eyebrow position and frontalis activity.

METHODS

This study involved the post hoc analysis of adult patients from the Phase 2a forehead lines (FHL, N = 60) and open-label safety (OLS, N = 175) studies who received a single dose of DAXI 40 U to the glabella and for whom facial photographs were taken at rest and at maximum eyebrow elevation. Median vertical and horizontal displacement of the brows and median forehead strain (an objective quantitative assessment of frontalis activity) from baseline to 2 weeks after glabellar DAXI injection were measured.

RESULTS

Two weeks after glabellar DAXI injection, vertical eyebrow movement (at rest) of the lateral brow was observed. In both studies, vertical movement was greatest in the lateral (0.6-0.9 mm) and mid (0.5-0.7 mm) brow regions; movement in the medial brow was negligible (0-0.23 mm). In both studies, a graded reduction in forehead strain was observed 2 weeks post glabellar DAXI injection, with the greatest reduction being in the lower segment (FHL, -73%; OLS, -82%). Treatment with DAXI showed improvements in FHL wrinkle severity.

CONCLUSIONS

Glabellar injection of DAXI showed a positive reduction in dynamic frontalis activity that maintained or had a positive effect on eyebrow position. Vertical movement of the brow was suggestive of an improved eyebrow shape with a mild lateral arch.

LEVEL OF EVIDENCE: 4

Expert Opinion on Non-Surgical Eyebrow Lifting and Shaping Procedures

Eyebrow elevation and reshaping are common concerns that we handle in everyday practice, and we have noticed that the trend is shifting from a medical concern to a cosmetic one. Several eyebrow lift methods are available, both invasive and non-surgical. The method of choice depends on several factors, such as patient expectations and beliefs, financial budget, acceptance of downtime and the available tools in the practice. In this article, we review the recent literature on non-surgical eyebrow lift methods to provide an overview of the current state of this field. We discuss seven different methods for eyebrow lift and reshaping, including botulinum toxin, dermal fillers, fractional radiofrequency, high-intensity focused ultrasound, thermo-mechanical ablation, lasers, and threads. Moreover, we provide practical insight into the procedure, injection techniques, expected results, and patient satisfaction rate.

Emerging off-label esthetic uses of botulinum toxin in dermatology

Botulinum toxin is a neurotoxic protein produced by Clostridium botulinum, the bacterium responsible for botulism. Botulinum toxin was first used for therapeutic indications in the 1970s for the treatment of strabismus. With greater understanding of its underlying physiology and safety profile, the use of botulinum toxin has now expanded to a range of cosmetic and medical indications. We performed a systematic review of current literature on the applications of botulinum toxin on off-label esthetic uses. Electronic databases were searched for original published studies including randomized trials, observational or cohort studies, as well as relevant case reports. To add to the body of evidence, our review summarizes and synthesizes key study characteristics, results, and level of evidence for each use case. Although the body of evidence remains weak, there is increasing support for the use of botulinum toxin in emerging off-label esthetic uses of botulinum toxin in dermatology.

Current Use of Cosmetic Toxins to Improve Facial Aesthetics

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin.

SUMMARY

Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.

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.

Hyperhidrosis and Aesthetics

When one considers the avalanche of new indications and uses for botulinum toxins, it is truly surprising that this has all happened in such a short time. And the safety and dependability of these products are profound, when used appropriately. There is still much to be discovered about the potential of this agent when you contemplate the profound non-cosmetic benefits reported by clinicians and scientists from around the world. The mechanism of action has been studied in depth, and yet the benefits appreciated by people with chronic migraine or major depressive disorder, for instance, are unlikely to be explained by our current mechanistic understanding. Given that these toxins control acetylcholine at the motor end plates, and given that acetylcholine is central to practically every cell in the body, it will not be surprising to find that botulinum toxin researchers will be enjoying many decades of fruitful studies. The advent of the non-surgical aesthetic physician has helped push the clinical utilization of botulinum toxins well beyond its original adoption by oculoplastic surgeons in their patients with blepharospasm. We can expect that the next edition of this book to have a dozen or more new indications which will surprise us all.

A 3D Morphometrical Evaluation of Brow Position After Standardized Botulinum Toxin A Treatment of the Forehead and Glabella

BACKGROUND

Botulinum toxin treatment for forehead wrinkles has been extensively studied and found to be a safe and reproducible procedure. However, the effect on the position of the eyebrows, which relies on the dynamic positioning of the treated muscles, has received less attention and has not been studied with 3-dimensional (3D) technology.

OBJECTIVES

The authors sought to evaluate the changes of eyebrow position after standardized botulinum toxin treatment of glabella or glabella and frontalis muscles with 3D imaging.

METHODS

In a prospective study, 2 groups of adult females were treated with botulinum toxin A at the glabella only (G) or at the glabella and the frontalis muscle (F/G). The brow position was measured at 5 positions with 3D photography before injection and 2 weeks, 3 months, and 6 months after injection. Results were statistically analyzed and related to patient age.

RESULTS

In the F/G group, the brow descended significantly almost across the whole brow length after 2 weeks. The descent lessened after 3 months and moved medially. No clear trend was evident in the G group. There was no significant change attributed to patient age in both groups.

CONCLUSIONS

Botulinum toxin treatment of the glabella and frontalis muscle impacts the position and configuration of the eyebrow. The degree of change is affected by the amount of frontalis weakening rather than by treatment of the glabella. While age in general is not a reliable predictor, individual factors play the major role in how pronounced a change of the brow can be expected.

LEVEL OF EVIDENCE: 2

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.

Overview of Botulinum Toxins for Aesthetic Uses

Botulinum toxin type A (BTA) can be used for facial aesthetics. The 3 currently available BTA types include onabotulinumtoxinA (Botox; Botox Cosmetic, Allergan, Irvine, CA), abobotulinumtoxinA (Dysport; Ipsen, Ltd, Berkshire, UK), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals, Frankfurt, Germany). The mechanism of action and clinical uses for treatment of dynamic lines of the forehead, brow, glabella, lateral orbit, nose, and lips are presented, as well as treatment of masseter hypertrophy, platysmal bands, and improvements of the perioral region. Specific BTA injection sites and suggested doses are presented.

The role of neurotoxins in the periorbital and midfacial areas

Initially popularized for the treatment of strabismus and blepharospasm, injection of botulinum neurotoxin has become the most commonly performed cosmetic treatment in the United States. Injection techniques have been particularly well-studied in the midface and periocular region, and patient satisfaction tends to be very high. We review the salient differences among available neurotoxins, how to optimally reconstitute them, how to inject the forehead, glabella, lateral canthal lines ("crow's feet"), infralid region, and transverse nasal lines ("bunny lines"), how to sculpt the brow, and how to manage potential complications.

Aesthetic use of BoNT: Options and outcomes

There are a multitude of uses for BoNT in the aesthetic realm. Efficacy has been shown in softening glabellar creases, crows feet, forehead rhytides, and in correcting facial asymmetries, including mild eyelid ptosis. Facial shape can be altered through injections of BoNT into masseter, and smiles can be altered with BoNT. Clinical examples of the above will be shown, as well as adverse outcomes with inaccurate injection techniques.

Effect of brow lifting using botulinum a toxin on upper eyelid height in patients with ptosis undergoing the frontal sling technique

In this study, brow lifting with botulinum A toxin was performed on patients whose ptosis was corrected using the frontal sling technique, and the effects of this application on ptosis were investigated. Seven patients (with 12 eyelids) on whom the frontal sling procedure was performed using a tensor fascia lata graft were enrolled in the study. The patients underwent brow lifting using botulinum A toxin. Digital photographs of the patients were obtained before and 21 days after botulinum A injection. In digital imaging analysis, although a statistically significant elevation was detected in the eyelids and brows of the patients following botulinum A injection, it did not to lead to a significant difference in the degree of lagophthalmos. In the current study, this procedure was found to reduce the degree of ptosis without increasing the degree of lagophthalmos in patients who had previously undergone ptosis correction using the frontal sling.

A succinct review of botulinum toxin in dermatology; update of cosmetic and noncosmetic use

Botulinum toxin A has a wide variety of clinical applications in medical and dermatologic sciences. Nowadays, researchers introduce some other indications for botulinum toxin in cosmetic and especially noncosmetic aspects of dermatology such as medical rhinoplasty, hypertrophic scar, chemical brow lift, supraciliary wrinkles, pompholix, eccrine angiomatosis, Hailey-Hailey, dermatochalasis, lichen simplex, nosthalgia parestetica, and granulosis rubra nasi. In this general overview of the use of botulinum toxin in dermatology, an extensive literature search was carried out to updates of all dermatology-oriented experiments and clinical trials on the mentioned aspect of botulinum toxin.

Noncosmetic periocular therapeutic applications of botulinum toxin

Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.

Surgical correction of aesthetically deformed eyebrows using local transposition flaps

BACKGROUND

Eyebrow positions differ in many ways. They vary in shape, thickness, length, and distance between the eyebrows, making the face more or less harmonious. When a large distance exists between the eyebrows and the medial brow is slanting downward, the glabellar area is larger, giving the face an awkward appearance.

METHODS

To correct this deformity, the authors propose using two Z-plasties to allow transposition of flaps in the region of the medial brow. The Z-shaped flap is outlined at the medial third of the brow, in the glabellar region, with the eyebrow centered in the lower portion of the "Z" and the hairless skin in the upper portion. The flaps then are transposed and sutured.

RESULTS

Transposition of the flaps, lifting the brow flap to the glabellar region, results in horizontal positioning of the medial and central third of the eyebrow.

CONCLUSION

The proposed transpositioning of "Z" flaps in this region corrects this type of deformity of the medial and central portions of the eyebrows, with an aesthetically satisfactory result.

Complications in periocular rejuvenation

Thorough preoperative evaluation with meticulous surgical planning to achieve facial aesthetic balance between the forehead, eyelids, and midface is imperative to avoid or decrease potential functional and/or cosmetic complications in cosmetic periocular surgery. Before performing surgery, the physician should be aware of the patient's history of dry eyes, previous facial trauma, previous injection of Botox Cosmetic, history of previous laser-assisted in situ keratomileusis, and past facial surgery. A full evaluation should be performed on the upper eyelid/brow region to assess for the presence of brow ptosis, brow/eyelid asymmetry, dermatochalasis/pseudodermatochalasis, eyelid ptosis, and deep superior sulcus. On the lower eyelid/cheek examination, special attention should be directed to the diagnosis of underlying negative vector, dry eyes, prominent eyes, lower lid retraction, ectropion, lateral canthal dystopia, lower eyelid laxity, scleral show, and lagophthalmos, with a rejuvenation goal that focuses on obtaining a youthful fullness through repositioning and reinforcing efforts to avoid the negative effects of hollowness. Intraoperative and postoperative medical and surgical management of cosmetic periocular surgery complications focus on decreasing the risk of postoperative ptosis, lagophthalmos, lid retraction, and lid asymmetry, with special attention to limiting the risk of visual loss secondary to orbital hemorrhage.

Attractiveness of eyebrow position and shape in females depends on the age of the beholder

BACKGROUND

Great diversity exists among individuals with respect to eyebrow position and shape, and the notion of an "ideal" eyebrow has changed quite significantly over the past several decades.

METHODS

This study compared three different variations of eyebrows. One variation was the arched eyebrow with the maximum height in the middle. The other two variations had their maximum height in the lateral third, but differed in their position (high vs low). For each of the seven female portraits presented, three variations were generated using morphing software. A total of 357 subjects 12 to 85 years of age compared these variations and ranked each woman individually with respect to perceived attractiveness.

RESULTS

The data show that the preference for a specific eyebrow shape depends on a person's age. Young subjects up to 30 years of age preferred eyebrows in a lower position, and ruled out arched eyebrows. Subjects older than 50 years stated exactly the opposite preference.

CONCLUSION

First, there is not one single beauty ideal for eyebrows, but at least three. The ideal a person prefers depends on his or her age. Second, because trends are generally introduced by young people and not by older individuals, and the young tend to prefer eyebrows in a lower position, it seems plausible to assume that the trend currently appears to be moving away from arched eyebrows toward lower positioned eyebrows with a maximum height in the lateral third.

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.

The results of periorbital rejuvenation with botulinum toxin A using two different protocols

BACKGROUND

This study was proposed to analyze the changes in shape and position of the eyebrow before and after botulinum toxin A injection using two different protocols for a periorbital rejuvenation.

METHODS

The botulinum toxin A treatment was performed for brow-lift and effacement of crow's feet (group A), and for brow-lift and effacement of glabellar frown lines in addition to crow' feet (group B). To evaluate the change in brow shape and height, measurements of five points around the brow were taken before and after treatment.

RESULTS

In groups A and B, the brow positions were elevated, and the interbrow distance was increased. The central brow showed the largest elevation, followed by the lateral brow and the medial brow. The difference in the interbrow distance between groups A and B was statistically significant (p < 0.001).

CONCLUSION

Elevation of the eyebrow with the desired aesthetically pleasing curvature was obtained after botulinum toxin A treatment in both groups using two different protocols for periorbital rejuvenation. The effect on the muscular dynamics after treatment can be changed according to the amount and the injection points. Therefore, in determining the injection protocols for periorbital rejuvenation, consideration should be given to the change in brow position and shape according to the change in the muscular dynamics after treatment.

Botulinum toxin - an update on its use in facial rejuvenation

The role of botulinum toxin in facial rejuvenation has been greatly expanded in the last several years. In this article, we first review the traditional approach to botulinum toxin therapy in the forehead and glabella. For the advanced reader, we then discuss both the literature and our personal approaches to treatments of the periocular region, mid face, lower face, and neck. Throughout the discussion, attempts are made to include a description of relevant anatomy, the physiologic result of specific muscle activity and denervation, and perhaps most importantly, precise directions for patient treatment.

Evolution of eyelid surgery

Cosmetic rejuvenation of the periorbital area has been an area of continual advancement in surgical knowledge over the past century. It is anticipated that some new currently described advances will be incorporated into continuing practice patterns, with advances in nonsurgical rejuvenation and surgical techniques.

Complications of botulinum toxin A use in facial rejuvenation

The esthetic application of botulinum toxin type A (Botox) is a safe treatment modality; nevertheless complications can occur as a result of patient-and physician-related factors. Fortunately, adverse effects and undesirable sequelae after Botox injections are temporary. Complications may be more serious in patients who have more severe rhytids (which require more Botox), previous facial plastic surgery (altered anatomy), and those who have pre-existing neuromuscular disease. The physician can reduce complications by using proper injection techniques, appropriate regional Botox dosing, and by being conservative in the overall approach to Botox-mediated facial rejuvenation.

[Botulinum toxin and wrinkles: few side effects and effective combining procedures with other treatments]

Chemical denervation, through the biologic effect of botulinum toxin, provides a very effective, low risk, lasting treatment for hyperkinetic wrinkles, mainly of the upper face. Patients with such rhytides, when treated with surgical myotomies or other alternative medical treatments, are at greater risk and with potentially less lasting results. Botulinum toxin has been widely used for the last 20 years in many areas of medicine. It has been used for 13 years in dermatology and plastic surgery, without important complications or sequellae. Any complications appear to be reversible. In these two specialties, with the minute quantities (units) and volume of material injected, complications are infrequent; some of them are now anecdotal. The only main complication from a cosmetic point of view is blepharoptosis, which is more and more rare. Because of a better anatomical knowledge of the affected muscles, and our improved technique, risks are greatly reduced. In our two latest multicenter studies on glabellar wrinkles, between 2002 and 2004, we saw no blepharoptosis. Conversely, in case of dynamic wrinkles associated with muscle, fat, and skin relapse, and/or deep furrows, only surgical procedures and/or other surface treatments are effective. Botulinum toxin injections are not meant to replace upper, mid, or mandibular face and neck lifts; indeed, botulinum toxin injections may optimize results from these surgical procedures. These injections play a fundamental process in producing long lasting results. The current and future evolution, in cosmetic surgery, is toward full achieved, but focused, natural, and minimally invasive surgical procedures in combination with effective and minimal risk techniques such as the botulinum toxin injections. To optimize the effect of the medical procedures, botulinum toxin should be injected three weeks before surgery. In addition botulinum toxin injections may optimize and prolong the effect of the surface procedures, as lasers, peels and fillers. This medicosurgical combination is one of the examples that best describes the evolution of plastic and aesthetic surgery in 2004.

New procedures in facial plastic surgery using botulinum toxin A

New indications for botulinum toxin A injection in facial plastic surgery have begun to emerge beyond the management of facial rhytids. This paper described a role for botulinum toxin in the rehabilitation from facial nerve paralysis, in the pharmacologic browlift, and in the nonsurgical management of platysmal bands. These procedures are not meant as a replacement for surgery, but rather as a less invasive alternative, or as an adjunctive modality. They are most useful in cases of functional or dynamic disorders, as opposed to problems of excessive or lax tissues. This article presented several clinical studies that give supportive evidence for the efficacy of the procedures. Further, larger studies with more objective measurements are necessary before these procedures become widely accepted.

A cosmetic approach to cutaneous defects

The options available to cosmetic surgeons for the treatment of the aging face are expanding at a rapid pace. Although any one modality may help, often a combination of approaches provides the most dramatic results. Whereas some of these techniques represent refinements of old tools, others represent entirely new modalities (Box 1). To tailor the most effective treatment plan appropriately, the limitations and strengths of these various tools must be understood by the patient and physician. During the preoperative consultation, assessment of a patient's expectations is critical when suggesting a treatment plan. By performing an assessment, the physician and patient can experience increased satisfaction because more optimal results are achieved.

Type A botulinum toxin in the upper aspect of the face

The use of botulinum toxin type A (BTX-A) for facial rejuvenation was first systematically developed by Carruthers and Carruthers on the upper aspect of the face. In the early 1990s, the first studies of the cosmetic use of BTX-A were published. BTX-A was only approved in 2002, however, by the U.S. Food and Drug Administration when extensive cosmetic studies were evaluated. The treatment of facial wrinkles with BTX-A has truly changed the concepts held by physicians regarding facial rejuvenation, mainly on the upper aspect of the face. It is one of the most common cosmetic procedures currently performed by physicians.

Chemodenervation for facial dystonias and wrinkles

PURPOSE OF REVIEW

Chemodenervation has evolved greatly over the past 30 years since botulinum toxin was first introduced as a therapeutic injection for managing strabismus.

RECENT FINDINGS

Botulinum toxins are now accepted as a first-line treatment for patients suffering from spasms secondary to facial dystonias. These treatments are extremely effective and well tolerated by most patients. New agents including doxorubicin, Doxil, and ricin mab35 are being developed to create a longer-lasting treatment option for patients with facial dystonias. Recently the use of chemodenervation for managing facial wrinkles has expanded the use of these agents. The botulinum toxins have been found to be extremely efficacious in managing facial wrinkles, especially in the upper half of the face. The federal drug administration approved the use of Botox (Allergan, Irvine, CA) for glabellar furrows. Periocular crow's feet lines and horizontal forehead lines are also amenable to treatment with the botulinum toxins. Further uses including chemical browlift, as well as lower face and neck line treatments have also been described.

SUMMARY

The use of the botulinum toxins has revolutionized the treatment of a broad array of diseases from benign essential blepharospasm to facial wrinkles.

Periocular botulinum toxin

Botulinum toxin type A (BOTOX, Dysport) has revolutionized treatment of wrinkles around the eyes. Since the first publications of its cosmetic benefit by Drs. Jean and Alastair Carruthers, hundreds of articles have been published about its cosmetic use. BOTOX holds U.S. Food and Drug Administration approval in the United States for treatment of glabellar lines. BOTOX is in widespread use worldwide and is currently the most popular cosmetic treatment in the United States.

Complications of botulinum toxin A use in facial rejuvenation

The esthetic application of botulinum toxin type A is a safe treatment modality; nevertheless, complications can occur as a result of patient- and physician-related factors. Fortunately, adverse effects and undesirable sequelae after Botox injections are temporary. Complications may be more serious in patients who have more severe rhytids (which require more Botox), have undergone previous facial plastic surgery (altered anatomy), and those who have preexisting neuromuscular disease. The physician can reduce complications by using proper injection techniques, appropriate regional Botox dosing, and by being conservative in the overall approach to Botox-mediated facial rejuvenation.

Altering brow contour with botulinum toxin

Brow position is determined by a dynamic interaction between depressor and elevator muscles. Botulinum toxin may be used to temporarily alter this equilibrium to result in a change in brow position. Knowledge of the anatomy of the brow depressors and elevators allows selective treatment of these muscles to effect a change in contour to elevate or depress a specific part of the brow. Botulinum toxin browlifting may result in an aesthetically pleasing, modest brow elevation; however, individuals who have significant brow ptosis would be better treated surgically.