Botulinum toxin - an update on its use in facial rejuvenation

"Predicting Facial Changes After Blepharoplasty"

INTRODUCTION

The primary goal of blepharoplasty for blepharoptosis and blepharochalasis is to elevate the upper eyelid to restore a full field of vision, although many surgeons also aim to provide a better aesthetic outcome. Several facial configuration changes may occur following blepharoplasty. This study examined the effectiveness of vessel clips to preoperatively predict facial configuration alterations.

METHODS

We retrospectively enrolled 93 consecutive patients who underwent blepharoplasty correction for blepharoptosis and blepharochalasis with eyebrow elevation. Frontal portrait images were taken at the initial examination without load, preoperatively with vessel clips, and without load at 6 months postoperatively for evaluations of eyebrow height, forehead wrinkle length, and procerus area wrinkle length. Subjective outcomes were also surveyed by questionnaires and interviews at 6 months post-surgically.

RESULTS

No significant differences were detected between preoperative measurements with vessel clips and recordings at 6 months postoperatively. Significant correlations were identified among the addition/reduction values for preoperative and postoperative measurements (eyebrow height and forehead wrinkle length: r=0.402, p<0.001; eyebrow height and procerus area wrinkle length: r=-0.327, p<0.01; forehead wrinkle length and procerus area wrinkle length: r=-0.488, p<0.001). Women more frequently described notable changes in wrinkles than men.

CONCLUSIONS

Postoperative facial change outcomes for blepharoplasty may be predicted using the simple but effective vessel clip test. A better understanding of surgical results can relieve patient anxiety and contribute to increased satisfaction.

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

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.

Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation

BACKGROUND

Although perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches.

METHODS

To identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen's kappa coefficient.

RESULTS

Perioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid's bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0).

CONCLUSION

A better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.

Glabellar contraction patterns: a tool to optimize botulinum toxin treatment

BACKGROUND

Botulinum toxin is a well-established treatment for dynamic glabellar lines. A previous study evaluated the existence of glabellar contraction "patterns," according to the predominance of eyebrow approximation, depression, or elevation movements, namely "U," "V," "convergent arrows," "omega," and "inverted omega."

OBJECTIVES

To confirm contraction patterns in the adult population for a better treatment approach and to verify whether changes occur after repeated treatment.

METHODS

Pairs of photographs-at rest and under contraction-from two groups were retrospectively analyzed: 334 adult volunteers with a predominance of specific movements, being verified and 36 previously treated individuals when they returned for re-injections.

RESULTS

The five glabellar contraction patterns were confirmed. Each individual's initial pattern reappeared upon waning of the toxin effect.

CONCLUSION

Interpersonal differences in facial animation are observed. Classifying glabellar wrinkles allows accurate treatment with botulinum toxin, injecting the most commonly recruited muscles with higher doses or into more sites. Muscles not so recruited are spared or injected with lower doses for more-effective and -natural results. Although botulinum toxin blockade causes recruitment of adjacent muscles, the initial muscle contraction pattern is resumed when the effect wanes.

Midface lifting with botulinum toxin: intradermal technique

BACKGROUND

An intradermal injection technique is a variation of the intramuscular or subcutaneous injection technique usually performed with botulinum toxin for facial rejuvenation. The technique applied to realign the imbalance of the facial muscles by weakening the downward pull of the depressors and allowing the levators to contract in a compensatory fashion results in midface lifting and rejuvenation.

AIMS

To address the intradermal injection technique of botulinum toxin for midface lifting.

METHODS

A restrospective review of the patients undergoing midface lifting during the year 2008, the procedure, the details of the injection technique, and outcomes are described.

RESULTS

An intradermal injection technique of botulinum toxin successfully gives rise to midface lifting and rejuvenation.

CONCLUSION

An intradermal injection technique of botulinum toxin treatment is effective for aesthetic improvement in the midface.

Botulinum toxin injections as a method for chemically denervating skeletal muscle to test functional hypotheses: a pilot study in Lepomis cyanellus

In this study, we demonstrate that botulinum toxin can be used to chemically denervate muscles to test functional hypotheses. We injected research-grade type A botulinum toxin complex into pectoral fin abductors (abductor superficialis) of green sunfish (Lepomis cyanellus) to determine whether chemical denervation would eliminate the ability of a particular muscle to contribute to overall pectoral fin movements. Reduction of target muscle activity occurred within 8 d of the injection, and paralysis was confirmed using electromyography. No paralysis was seen in the adjacent muscles (abductor profundus) or in positive controls (saline injections). Paralysis occurred more slowly and at lower doses than previously documented for mammals. However, botulinum toxin complex (500 kDa) was used here, whereas previous studies have used purified toxin (150 kDa). Therefore, differences in physiological responses between fish and mammals cannot yet be distinguished from differences caused by the toxin type. However, we note that the toxin complex is less likely to diffuse across muscle fascia (because it is large), which should minimize paralytic effects on adjacent muscles. We suggest that botulinum toxin holds great promise as a chemical denervation agent in functional studies of animal locomotion and feeding behaviors.