Introduction
CHAPTER 57 Neuromodulators
Douglas C. Wu
SUMMARY
The most popular dermatologic uses of BTX include the reduction of facial
rhytides, facial contouring, and treatment of focal hyperhidrosis. It is commonly used for the following areas of the face:
Upper face
Glabellar lines
Lateral canthal lines
Horizontal forehead lines
Bunny lines
Infraorbital region
Lower face
Nasal tip droop
Nasal flare
Perioral rhytides
Depressor anguli oris
Hypertrophic masseters
Excessive gum show
Wrinkled chin
Beginner Tips
Expert consensus guidelines recommend that a vial of BTX can be refrigerated or
refrozen for at least 4 weeks before injection without significant risk for contamination or decreased effectiveness, and that a single vial can be used to treat multiple patients, assuming appropriate handling.
Using preservative-containing sterile normal saline for reconstitution significantly
reduces subsequent injection pain and is therefore recommended.
Expert Tips
Variations in muscular patterns in the upper face are well established, and studies have
demonstrated that targeted individualized treatment delivers superior outcomes.
Due to the interrelationship between the facial musculature, it is useful to
conceptualize the upper and lower face as global treatment regions rather than focus on a specific area such as the glabella or lateral canthus. This mindset promotes the goal of achieving a harmonious, balanced, natural, and aesthetically pleasing outcome.
Don’t Forget!
Simple mechanical distraction administered by an assistant tapping on the patient’s
shoulder or forehead during injections is a highly effective and efficient way to decrease injection pain.
Brow ptosis is especially common in those with smaller foreheads, naturally low
brows, minimal frontalis bulk, or with a tendency to overutilize the frontalis muscle for brow elevation during facial expressions.
Pitfalls and Cautions
Cultural and ethnic norms should also be taken into account when tailoring individual
treatments, as desires and expectations can vary significantly between these diverse populations.
Inferolateral extension of lateral canthal lines down toward and across the zygoma
should not be “chased” with BTX due to the risk of facial asymmetry.
Patient Education Points
Important areas to consider include: establishment of realistic goals, assessment of
desired treatment area, understanding of expectations and potential side effects, written informed consent, and photographic documentation.
Photographic documentation is highly recommended for both pre- and posttreatment
status.
CHAPTER 57 Neuromodulators
INTRODUCTION
Botulinum toxin (BTX) is one of the most widely used aesthetic treatments available to dermatologists and dermatologic surgeons. When appropriately applied, its safety, efficacy, reproducibility, and overall satisfaction are exceptional.
Although the toxin itself was isolated in the 1940s, early work with BTX for medical purposes began in the 1970s and 1980s with the pioneering research of Dr. Alan Scott on strabismus and blepharospasm. Experiments in monkeys1 laid the groundwork for successful clinical trials in humans.2,3 In 1989, BTX received Food and Drug Administration (FDA) approval for blepharospasm and nystagmus.
In parallel with the above efforts, the ophthalmologist–dermatologist, wife–husband team of Jean and Alastair Carruthers made an unexpected discovery: a subject being treated for blepharospasm in a clinical trial reported that BTX therapy also seemed to give her an untroubled, unworried appearance.4 Seizing upon this observation, the Carruthers explored the potential of BTX therapy for aesthetic concerns and published their initial work in 1992.5 This report spawned the ensuing decades of research and refinement of the dermatologic uses for BTX. In the present day, BTX therapy forms a cornerstone in the dermatologic surgeon’s armamentarium for facial rejuvenation and beyond.