To Tox or not to Tox?
Where – is the question.
The widespread emergence of botulinum neurotoxins in the field of aesthetics is actively being researched and on the precipice of larger applications. Despite the relative novelty of the field, a lot has already been determined with regards to its effectiveness in different applications. In continuation of the overview on botulinum toxins, this article presents a lens into the general guidelines and treatment recommendations pertaining to facial injection and its associated topography.
General Guidelines
A couple of general guidelines to minimize discomfort of the patient include the use of topical anesthetics or the application of ice packs to the skin prior to injection. To further minimize bruising, patients should discontinue any medications that interfere with the stopping of blood flow (hemostasis) 10 to 14 days prior to injection, and the smallest gauge needle should be used. The spread of injected BTA can be up to 3 cm from the injection site, so the concentration of the substance should be taken into consideration when the desire is to increase diffusion – or more often limit it when targeting a highly specific area
Upper Face
Due to less volume loss over time than other parts of the face and the development of rhytides being the predominant age marker, treatment of the area generally yields good to excellent results.
Transverse Forehead Rhytides |
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Two main considerations for success in the treatment of transverse forehead rhytides are the comparative presence of dynamic versus static rhytides, and review of the general forehead anatomy of the patient as pertaining to their muscle strength, muscle orientation, and brow height, to name a few. |
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Women: 10-20 Units |
Frontalis muscle |
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Men: 16-24 Units |
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Glabellar Region |
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FDA-approved aesthetic use of BTA in 2002 was for the glabellar region and it remains the most frequent indication for its use. Treatment of glabellar rhytides with botulinum toxin type A can improve quality of life and may reduce negative moods – a high level of satisfaction has been shown even 4 months after treatment. |
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20 Units divided among 5 injection sites (on-label)
Women up to 30 units
Men up to 40 units |
Paired corrugator supercilii muscles Central procerus muscle |
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Brow Lift |
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Often combined with the treatment of the glabellar complex and frontalis, the lateral brow lift is most often performed as a component of treating the rest of the face. Glabellar complex treatment alone has also been found to lift the lateral brow by as much or more than the medial brow. |
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2 to 5 Units |
Orbicularis oculi muscle |
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Lateral Orbital Region (Crow’s Feet) |
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A well documented use, BTA successfully softens the appearance of crow’s feet (lateral canthal lines), the result of hyperkinetic orbicularis oculi muscles. |
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Starting Doses
Women: 8-10 Units |
Orbicularis oculi muscle (targeting the preorbital region) |
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Men: 12-16 Units |
Mid-Face
Treatment with botulinum toxin has a more limited role than dermal fillers or surgical resuspension because of volume loss and descent more prevalent in the area.
Oblique Nasal Sidewall Rhytides (Bunny Lines) |
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Caused by hyperactivity of the transverse portion of the nasalis muscle |
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2-5 Units per side |
Nasalis muscle: paired structure, consisting of an alar and transverse portion |
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Upper Lip |
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Although it can be exacerbated by activities such as smoking and sun exposure, vertical perioral rhytides are a universal marker of increasing age. Although BTA can improve dynamic (and to some extent, static) rhytides, they are often used in conjunction with dermal fillers to improve the contour and volume loss in the lip. |
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4-6 Units |
Orbicularis oris muscle |
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Lower Face and Neck
As mentioned with the mid-face, treating aging-related changes in the lower face and neck are more successfully done with the restoration of volume and resuspension of descended tissues, although several aesthetic indications for treatment with BTA exist.
Depressor Anguli Oris |
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A downturn in the corner of the mouth, often causing an angry or sad look, is created by the contraction of the depressor anguli oris (DAO). BTA treatment of these muscles can reduce the downward pull and provide a subtle lift, reducing the DAO contraction and de-accentuating the melomental fold. |
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2-5 Units |
Depressor anguli oris |
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Mentalis |
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The appearance of wrinkling or dimpling of the chin (referred to as peau d’orange), this is most often visible when the facial muscles are engaged and is not often an indication. |
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5-10 Units |
Mentalis muscle |
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Masseteric Hypertrophy |
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Creating a square or “masculine” appearance to a female face, the enlargement of the masseter can be treated with BTA although genetic and habitual components are involved in the pathogenesis. |
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Starting Doses
30-35 Units |
Masseter |
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Platysmal Banding |
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The aging of the neck is a continuing challenge to aesthetic practitioners, and many issues associated with aging require surgical intervention. However, BTA can play a role in rejuvenation with the improvement of vertical platysmal banding and horizontal rhytides. |
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~ 30-40 Units
Important to keep to less than 50 Units per session
(with significant variability reported in literature) |
Platysma Muscle |
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Overall, the aesthetic uses of injectable botulinum toxins in the face are extensive and patient satisfaction with treatment is very high. For both practitioners and patients, the goal of treatment has shifted from an ironed, “frozen” look, to a softer one preserving natural expression through the dampening of muscular activity. Treatment has overall proven more effective on dynamic facial rhytides as opposed to static ones, and it will not necessarily serve as a substitute for other facial procedures. As always, clear communication with realistic, individually assessed expectations and goal setting with the patient are paramount for successful results.
References
Gart, Michael & Gutowski, Karol. (2016). Overview of Botulinum Toxins for Aesthetic Uses. Clinics in Plastic Surgery. 43. 10.1016/j.cps.2016.03.003.
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