The adjunctive usage of botulinum toxin

Buccal Fat Pad Augmentation for Midfacial Rejuvenation: Modified Fat Grafting Technique and Ogee Line Remodeling

BACKGROUND

The volume and position of the buccal fat pad (BFP) change with age, which manifests as a hollow midface. Previous studies showed that autologous fat grafting for BFP augmentation could effectively ameliorate midfacial hollowing.

OBJECTIVES

The aim of this study was to introduce a modified fat grafting technique for female patients with midfacial hollowing to restore the volume of BFP, and to evaluate the safety and effectiveness of this approach.

METHODS

Two cadavers were used for the dissection of the BFP and to demonstrate the surgical procedures. Forty-eight patients were treated for midfacial hollowing with the modified grafting strategy. The BFP was filled through a percutaneous zygomatic incision and an immediate amelioration in the hollow area was observed. Improvements were evaluated from measurements of the ogee line and ogee angle, FACE-Q questionnaires, and 3-party satisfaction ratings. Clinical profiles were reviewed and statistically analysed.

RESULTS

The mean [standard deviation] ogee angle was 6.6° [1.9°] preoperatively and 3.9° [1.4°] postoperatively (average reduction, 2.7°). Patients' ogee lines were smoother postoperatively, with marked improvements in overall appearance, psychological well-being, and social confidence. Patients reported high satisfaction with decision-making and postoperative outcomes and felt 6.61 [2.21] years younger. Overall, 88%, 76%, and 83% of the cases were graded as good or excellent in improvement by surgeon, patient, and the third party, respectively.

CONCLUSIONS

For age-dependent midfacial hollowing in female patients, the modified percutaneous grafting technique described here was safe and efficacious in restoring BFP volume. This technique produced a smoother ogee line and a natural, younger midfacial contour.

LEVEL OF EVIDENCE: 4

Tissue Modification in Nonsurgical Facelift Options

Nonsurgical facelifts are a term for a heterogeneous group of procedures used by physicians to improve facial rejuvenation without the use of operative techniques. Patients demand these services due to the reduced recovery time and generally lower risk. However, nonsurgical techniques, to be effective, must induce conformational change in the cells and tissues of the face. Therefore, these techniques are significant procedures that have associated risks. Understanding the tissue modifications and mechanisms of action of these techniques is vital to their safe and effective use. The purpose of this article is to provide a background of tissue modification in nonsurgical facelift options.

Effect of Botulinum Toxin A on Muscle Healing and its Implications in Aesthetic and Reconstructive Surgery

BACKGROUND

Muscle activity contributes to the enhancement of facial aging deformity, blepharospasm, cerebral palsy spasticity, trismus, torticollis, and other conditions. Myotomy of the involved muscles in order to reduce the deformity has variable success rates due to muscle healing and regeneration of activity.

OBJECTIVES

The goal of this study was to investigate whether blocking striated muscle activity with Botulinum toxin (BtxA) during the healing time after myotomy alters the healing process and reduces long-term muscle activity.

METHODS

Eighteen Sprague Dawley rats where divided into 3 groups: group A (n = 7) underwent myotomy of their Latisimus Dorsi muscle; group B (n = 7) underwent myotomy and injection of BtxA into their severed muscle; group C (n = 4) injection of BtxA only. Muscle strength was tested periodically using a grip test.

RESULTS

Starting at week 16 and until the termination of study at week 22, group B (Myotomy + BtxA) showed significant reduction in muscle power compared to the two control groups.

CONCLUSIONS

Addition of BtxA injection into a muscle immediately after myotomy may interfere with muscle healing and contribute to a more successful long-term result.

The Power of Combined Therapies: BOTOX and Ablative Facial Laser Resurfacing

Introduction:

The etiology of facial rhytides is multifactorial. Static rhytides are caused by environmental factors and heredity, whereas dynamic rhytides are caused by the repetitive action of muscles during facial expressions. A successful multifactorial therapeutic approach is to use ablative laser resurfacing to reduce the static component and BOTOX to soften the dynamic component of the facial rhytide.

Materials and Methods:

We retrospectively analyzed the charts and photographs of 53 consecutively treated subjects to evaluate the relative strengths of the static and dynamic treatment modalities on the individual's final aesthetic result. To remove any potential for bias, the treatments were all carried out by author J.C. The photographic and chart reviews were performed by author A.C., and the subjective patient questionnaire was completed by author A.Z.

Results:

Adding BOTOX to CO2 laser resurfacing improved the result objectively from 30% to 60%. However, adding BOTOX to Erbium:YAG laser resurfacing improved the result only marginally (40% to 47%).

Discussion:

Combined therapy with CO2 laser resurfacing and BOTOX gave the most pronounced aesthetic benefit. Combined treatments with Erbium-YAG laser resurfacing and BOTOX was a less powerful treatment blend.

Treatment of lateral canthal rhytides with a medium depth chemical peel with or without pretreatment with onabotulinum toxin type A: a randomized control trial

Background

Combination therapies used to treat the photoaged skin have become more popular as studies demonstrate greater efficacy and improved clinical outcomes compared to single treatment modalities.

Objectives

To evaluate the safety and effectiveness of treating the lateral canthal rhytide complex with a Jessner’s and 35% TCA peel with and without pretreatment with BTX-A.

Methods

Twenty-six subjects with Fitzpatrick skin types I -III were randomized to receive treatment of their lateral canthal rhytide complex with a Jessner’s and 35% TCA peel with or without pretreatment with BTX-A. A single blinded dermatologist assigned a lateral canthal wrinkle score of subjects’ at baseline and week 8-10.

Results

Comparison between the two treatment groups demonstrated that the group receiving combination treatment had significantly greater improvement in wrinkle reduction as compared to the group only receiving the chemical peel (P =0.002). In addition, there was no significant association between skin type and treatment groups (P = 0.11).

Conclusions

These findings suggest that treating the lateral canthal rhytide complex with a combination of BTX-A followed by Jessner’s and 35% TCA peel is more effective than chemical peel alone. These results are independent of skin type and demonstrate an additional treatment strategy for lateral canthal rhytides.

Botulinum toxin the poison that heals: A brief review

Botulinum neurotoxins, causative agents of botulism in humans, are produced by Clostridium botulinum, an anaerobic spore-former Gram-positive bacillus. Botulinum neurotoxin poses a major bioweapon threat because of its extreme potency and lethality; its ease of production, transport, and misuse; and the need for prolonged intensive care among affected persons. This paper aims at discussing botulinum neurotoxin, its structure, mechanism of action, pharmacology, its serotypes and the reasons for wide use of type A, the various indications and contraindications of the use of botulinum neurotoxin and finally the precautions taken when botulinum neurotoxin is used as a treatment approach. We have searched relevant articles on this subject in various medical databases including Google Scholar, PubMed Central, ScienceDirect, Wiley Online Library, Scopus, and Copernicus. The search resulted in more than 2669 articles, out of which a total of 187 were reviewed. However, the review has been further constricted into only 54 articles as has been presented in this manuscript keeping in mind the page limitation and the limitation to the number of references. A single gram of crystalline toxin, evenly dispersed and inhaled, can kill more than one million people. The basis of the phenomenal potency of botulinum toxin (BT) is enzymatic; the toxin is a zinc proteinase that cleaves neuronal vesicle-associated proteins responsible for acetylcholine release into the neuromuscular junction. A fascinating aspect of BT research in recent years has been the development of the most potent toxin into a molecule of significant therapeutic utility. It is the first biological toxin which is licensed for the treatment of human diseases. The present review focuses on both warfare potential as well as medical uses of botulinum neurotoxin.

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.

Use of intraoperative botulinum toxin in facial reconstruction

BACKGROUND

Botulinum toxin is a potent neuromodulator that temporarily relaxes muscles and can improve wound healing.

OBJECTIVE

This retrospective analysis assessed the use of intraoperative botulinum toxin type A or B in patients undergoing surgical reconstruction after Mohs micrographic surgery for treatment of skin cancer. The primary effect of intradermal botulinum toxin on wound healing was also studied.

METHODS & MATERIALS

Charts of patients who received intraoperative botulinum toxin type A (n=9) or B (n=9) in conjunction with reconstructive surgery after Mohs micrographic surgery were reviewed. Three volunteers also underwent dermal injections of botulinum toxin type A followed by erbium laser resurfacing.

RESULTS

Outcomes did not differ in patients treated with botulinum toxin type A and type B. Patients had excellent apposition of wound edges and smooth skin overlying soft tissue; no significant complications were noted. Healing of erbium laser ablation did not differ between botulinum toxin type A-treated skin and control skin.

CONCLUSIONS

Administration of botulinum toxin type A or B after reconstruction after Mohs micrographic surgery aided wound healing; botulinum toxin type A and botulinum toxin type B were equally effective. Intradermal botulinum toxin type A demonstrated no primary effect on healing of erbium laser-resurfaced skin.

Lasers and optical technologies in facial plastic surgery

Lasers and optical technologies play a significant role in aesthetic and reconstructive surgery. The unique ability of optical technologies to target specific structures and layers in tissues to effect chemical, mechanical, or thermal changes makes them a powerful tool in cutaneous rejuvenation, hair removal, fat removal, and treatment of vascular lesions such as port-wine stains, among many other procedures. With the development of adjunct techniques such as epidermal cooling, lasers and optical technologies have become more versatile and safe. The constant improvement of existing applications and the emergence of novel applications such as photodynamic therapy, nanoparticles, spectroscopy, and noninvasive imaging continue to revolutionize aesthetic medicine by offering a minimally invasive alternative to traditional surgery. In the future, therapies will be based on individualized, maximum, safe radiant exposure to deliver optimal dosimetry. Lasers and optical technologies are headed toward safer, easier, more quantifiable, and more individualized therapy.

[Treatment of wrinkles with botulinum toxin]

The use of botulinum toxin A for the treatment of wrinkles is increasing. Botulinum toxin A inhibits exocytosis of acetylcholine from 3 to 12 months, depending on the target tissue. Low-dose botulinum toxin A is used to smooth hyperkinetic facial lines. This is especially successful in the upper facial parts, since the target muscles (procerus, corrugator supracilii, frontalis, orbicularis oculi) all directly overlie the osseous structures of the face. This is not the case for the lower facial parts, and more side effects are encountered when treating, for example, wrinkles around the mouth. Contraindications to the use of botulinum toxin A are diseases affecting neuromuscular signal transduction, allergic reactions to components of the solution, therapy with aminoglycosides or acetylsalicylic acid prior to treatment, infections in the planned treatment area, and pregnancy and lactation. Alternative and complementary treatments include erbium-YAG or CO2 laser, as well as augmentation and surgical plastic procedures.

Combined Nonablative Rejuvenation Techniques

BACKGROUND

Nonablative technologies have been used for fine lines and improvement of skin texture without significant downtime. Nonablative technologies may also be used in combination.

OBJECTIVE

To present a brief review on nonablative technologies and discuss using nonablative procedures in combination and with other adjunctive therapies.

MATERIALS AND METHODS

A review of the literature was done to identify combination nonablative studies. We also discuss our own experience in combining these procedures.

RESULTS

Various nonablative technologies can be used together, often with better outcomes and fewer treatments.

CONCLUSION

Nonablative and adjunctive treatments should be performed in combination to optimize the results. Much of the information in this publication is from personal experience and expresses the opinions of these authors while citing relevant literature and studies.

[Skin, wrinkles and botulinum toxin]

OBJECTIVE

To present an up-to-date analysis about the use of botulinum toxin for treating facial lines and wrinkles.Method. - A systematic search of the literature was conducted to select the most recent or relevant publications on this topic, through Medline.

RESULTS

Out of the 583 articles retrieved, 90 were finally selected for the study.

DISCUSSION

Validity of using botulinum toxin for cosmetic use is demonstrated, together with contra-indications and different methods to objectivate the results. The different available types of toxin are presented and compared. Modalities of preparation, conservation, and waste disposal are detailed. Anatomical bases of muscular facial balance are reviewed, with techniques of injection presented for each site, and also with adjunctive procedures. Complications and side effects are described and analysed. Most complications can be prevented through: perfect knowledge of local anatomy;use of small volumes;orientation of the needle bevel towards the muscle body, injection within the muscle body if thick, more superficial if thin;application of ice on the skin pre- and post-injecting. Adding epinephrin or diluting with xylocaïne and epinephrin is not commonly used.

CONCLUSION

Botulinum toxin has found its way as a major component of the therapeutic armamentarium. Its efficacy for facial rejuvenation has made it extremely popular, but its use does follow strict rules, and should be restricted to soundly trained practitioners.

Botulinum toxin type A: history and current cosmetic use in the upper face

This article reviews the cosmetic use of botulinum toxin in upper face from both the historic and clinical viewpoints. The published literature and our current experience are outlined. Botulinum toxin type A in the upper face has become an extremely popular cosmetic procedure and is outstandingly safe.

Browlift with botulinum toxin

BACKGROUND

Botulinum toxin has been used successfully for the treatment of hyperfunctional facial lines.

OBJECTIVE

To determine the alteration in brow position after botulinum toxin treatment of the brow depressor muscles.

METHODS

Eleven women, 30-60 years old, were treated. Prior to treatment, brow position was measured relative to the pupil. Relaxed position and elevated position with frontalis contraction were evaluated. Botulinum toxin was injected into bilateral eyebrows. Each brow received one injection into the glabellar region (5 U) and four equally spaced injections along the lateral orbital rim below the brow (total of 10 U). Brow position was measured for postinjection relaxed and elevated positions at three points, from the central pupil to the nasal, central, and temporal brow.

RESULTS

A statistically significant elevation of the right and left brows was observed in both relaxed and elevated positions. The largest mean elevations were noted in the right central brow position (relaxed 1.86 mm, elevated 2.09 mm) and the left central brow position (relaxed 3.06 mm, elevated 2.86 mm).

CONCLUSION

Botulinum toxin is a safe and effective treatment for temporary browlift. The elevations produced in the nasal, central, and temporal brow can produce an aesthetically pleasing female brow with desirable shape and height.

Clinical indications and injection technique for the cosmetic use of botulinum A exotoxin

BACKGROUND

Some wrinkles and unsightly facial expressions are due to overactivity of the underlying facial musculature. Botulinum A exotoxin reversably paralyses selected muscles. Botulinum toxin has been used to correct facial cosmetic concerns.

OBJECTIVES

This paper describes the authors' experience with the cosmetic use of botulinum toxin. The areas that can be treated, the appropriate technique for each area and special considerations such as dose, dilution, and relevant anatomy are discussed.

RESULTS

Our results have been published previously and are referenced in this paper.

CONCLUSIONS

Botulinum toxin is safe and effective in the management of some facial lines and wrinkles. Its use is associated with a high degree of patient and physician satisfaction.