Treatment of nasal wrinkles with botulinum toxin

Use of LetibotulinumtoxinA for Aesthetic Treatment of Asians: A Consensus

Treatment of wrinkles and dynamic lines with botulinum toxin has been a routine practice for years in aesthetic clinical settings. The effective treatment of wrinkles requires a comprehensive understanding of facial expression muscles and their interactions, the mechanism of action of botulinum toxin, and individual patient preferences. The dose adjustment practice and injection technique of physicians are affected by cultural differences; most Asian patients prefer natural-looking results. This article aims to present an expert consensus on the injection sites, doses, and levels of botulinum toxin for various indications in Asians, with the hope of providing guidance to some clinicians. This consensus paper reviews LetibotulinumtoxinA for patient evaluation, dosage, and delivery techniques in Asians from the time LetibotulinumtoxinA was approved up to December 2022. Panelists proposed individualized treatment plans for botulinum toxin type A (BTxA) treatments in 3 areas-wrinkle removal, contour adjustment, and face lifting-for Asians based on their extensive experience and knowledge of facial anatomy. When using a different BTxA, clinicians should start with a conservative dose and carefully individualize the treatment for each patient, and adjust it according to feedback to obtain a higher satisfaction level.

LEVEL OF EVIDENCE: 5

Dynamic evaluation of facial muscles: 3D skin displacement vector analysis using a facial painting model

BACKGROUND

Botulinum toxin A can be used to eliminate dynamic wrinkles by relaxing the muscles involved in facial expressions. Therefore, it is essential to know the location, origin, insertion, function, and changes of the facial expression muscles according to their contraction.

METHODS

After drawing the muscles on the face of a model, pictures were taken at rest. The model was then asked to make facial expressions that cause facial wrinkles. All images were taken with the Vectra H1 camera system (Canfield Scientific, Inc., Fairfield, New Jersey). Each expression image was aligned to its respective static image to compute the differences in skin position, so as to calculate the skin displacement vectors. The values for local changes in skin displacement were calculated by applying the automated algorithms of the Vectra Software Mirror Suite and visualized using the color and size of the arrow.

RESULTS

Face painting and 3D skin vector displacement analyses enabled visualization of all the facial muscles involved in facial expressions working dynamically, allowing us to visualize the effect of each muscle in the creation of hyperkinetic wrinkles. Face painting and 3D skin vector displacement analyses can be combined to determine the location of the wrinkles, extent of the muscle, part of the muscle that contracts, presence of asymmetry, direction in which the muscle contracts, and correlation between the antagonists and synergistic muscles.

CONCLUSION

The botulinum toxin A injection educational model using body painting and 3D skin vector displacement analyses can provide a deeper understanding of actual moving muscle anatomy.

LEVEL OF EVIDENCE

4.

Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A-Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations

BACKGROUND

Combination of fillers and botulinum toxin for aesthetic applications is increasingly popular. Patient demographics continue to diversify, and include an expanding population receiving maintenance treatments over decades.

METHODS

A multinational panel of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated guidelines with a worldwide perspective for hyaluronic acid fillers and botulinum toxin. This publication considers strategies for combined treatments, and how patient diversity influences treatment planning and outcomes.

RESULTS

Global Aesthetics Consensus Group recommendations reflect increased use of combined treatments in the lower and upper face, and some midface regions. A fully patient-tailored approach considers physiologic and chronologic age, ethnically associated facial morphotypes, and aesthetic ideals based on sex and culture. Lower toxin dosing, to modulate rather than paralyze muscles, is indicated where volume deficits influence muscular activity. Combination of toxin with fillers is appropriate for several indications addressed previously with toxin alone. New scientific data regarding hyaluronic acid fillers foster an evidence-based approach to selection of products and injection techniques. Focus on aesthetic units, rather than isolated rhytides, optimizes results from toxin and fillers. It also informs longitudinal treatment planning, and analysis of toxin nonresponders.

CONCLUSIONS

The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Combined treatment is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related, and that successful treatment entails identifying and addressing the primary causes of each.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications

BACKGROUND

Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction.

METHODS

A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications.

RESULTS

Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action.

CONCLUSIONS

The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Selection and preference for botulinum toxins in the management of photoaging and facial lines: patient and physician considerations

Various noninvasive to minimally invasive techniques can be used for the improvement of cutaneous changes seen with photoaging. These include dermabrasion, chemical peels, ablative and nonablative lasers, and filler agents such as hyaluronic acid. However, the most common nonsurgical cosmetic procedure performed in the treatment of rhytides is injection with botulinum toxin. Its extensive safety history and relative ease of use by the practitioner has led to high satisfaction in millions of patients. Nonetheless, proper training of the fundamentals in injection technique, the choice of the appropriate candidate, and knowledge of potential adverse events are imperative to ensure a satisfactory and safe outcome.

Update on Botulinum Toxin

Botulinum toxin for facial enhancement is currently the most popular aesthetic procedure performed in the United States. New developments have occurred within the last few years. Patients prefer having multiple areas of the upper face treated which increases patient satisfaction. Treatment of the forehead is now being accomplished with fewer units of botulinum toxin. This helps preserve the natural look of some movement of the forehead. Men require more units of botulinum toxin than women. Combination therapy using botulinum toxin along with lasers or filler substances is ideal. Aesthetic medicine knowledge has progressed, contributing a greater understanding of botulinum treatment for advanced areas of the face. The orbicularis oris, mentalis, and depressor anguli oris are now routinely treated and help improve overall facial appearance. Other forms of botulinum toxins (additional type A or type B toxins) are available, each with advantages and disadvantages.