cme the cosmetic use of botulinum toxin - jeffrey janis plastic … · 2014. 7. 18. · cial...

CME

The Cosmetic Use of Botulinum ToxinRod J. Rohrich, M.D., Jeffrey E. Janis, M.D., Steven Fagien, M.D., and James M. Stuzin, M.D.Dallas, Texas; and Boca Raton and Miami, Fla.

Learning Objectives: After studying this article, the participant should be able to: 1. Discuss the basic science behindchemodenervation. 2. Describe examples of injection techniques for various facial areas. 3. Discuss potential side effectsand their avoidance.

The approach to facial rejuvenation continues toevolve. For decades, the primary focus on rejuvenation hascentered on modalities such as skin care, skin resurfacing,soft-tissue augmentation, and surgical intervention. A bet-ter understanding of the physiologic changes that occurwith facial aging lends itself to new approaches and tech-niques that are mindful of the causes. As animation hasshown to be a significant contributor to both the appear-ance of facial lines and soft-tissue malposition, there hasbeen recent interest in chemodenervating agents andtheir applications in the field of facial rejuvenation. Theseagents, by and large, efface rhytides by selective and pre-cise focal paralysis of the underlying facial musculatureand, therefore, reduce or eliminate the prominence of theoverlying rhytides. In addition, chemodenervation canserve as an adjunct for facial rejuvenation because of itsinfluence on facial soft-tissue position and shape. Botuli-num toxin, derived from Clostridium botulinum, is the mostwidely used agent; therefore, this new modality, its appli-cations in cosmetic plastic surgery, and its applications toother areas will be discussed. (Plast. Reconstr. Surg. 112(Suppl.): 177S, 2003.)

Botulinum toxin is derived from the bacte-rium Clostridium botulinum, which is an obligateanaerobe. There are eight different subtypes ofbotulinum toxin (A, B, C1, C2, D, E, F, andG),1 although only two (types A and B) arecurrently manufactured for commercial use.All eight subtypes effect muscular paralysis bypreventing the release of acetylcholine fromthe presynaptic neuron at the neuromuscularjunction, but they do so at different target sitesand with variable effectiveness.2,3 Botulinum

toxin A is the most potent of all the subtypesand, therefore, is the one clinically used mostfrequently. Its effects are both dose dependentand reversible.4 Muscle weakness can be appre-ciated as soon as 6 hours after exposure. How-ever, full paralysis and obvious clinical effectsusually manifest by 7 days5 (though sometimeseven longer), and last between 3 and 6 months.Physiologic and clinical effects dissipate as newneuromuscular junctions develop and axonalsprouting takes place.6

The first described use of botulinum toxin asan injectable local paralytic agent was by Scottin 1980, when he used the toxin to managestrabismus caused by ocular muscle spasticity.7Subsequently, botulinum toxin has been ap-plied in the management of various disorders,including but not limited to various dystonias,facial and generalized muscle spasms andother spastic muscle disorders, autonomic dis-orders, migraine headaches, and involuntarymovement disorders.8–39

The first described use of the toxin in aes-thetic circumstances was by Clark and Berris in1989,40 when it was used to help correct facialasymmetry caused by facial nerve paralysis afterrhytidectomy. In 1992, Carruthers and Car-ruthers41 reported positive effects of the toxinon the appearance of deep glabellar furrows inpatients treated in the periorbital region forbenign essential blepharospasm. Its uses in fa-

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center; Aesthetic Eyelid Plastic Surgery, Private Practice;and the Department of Plastic Surgery, University of Miami School of Medicine. Received for publication January 13, 2003; revised March 11,2003.

Drs. Rohrich and Fagien currently co-chair the Plastic Surgery Educational Foundation’s committee, sponsored by Thomson AdvancedTherapeutics Communications, to educate board-certified plastic surgeons on the clinical use of botulinum toxin type A. They own no stock orstock options in Allergan, Elan, or Ipsen. Dr. Rohrich has served as a consultant to Elan.

DOI: 10.1097/01.PRS.0000082208.37239.5B

177S

cial rejuvenation have blossomed since thattime, although all of these applications wereconsidered “off-label” uses. On April 15, 2002,the U.S. Food and Drug Administration ap-proved the use of botulinum toxin type A toameliorate moderate to severe glabellar rhyt-ides.42 Other common cosmetic uses, such asthe treatment of crow’s feet, perioral rhytides,and platysmal bands, still remain off-label.43–60

THE PRODUCT

There are currently three botulinum toxinformulations available, two of the A subtypeand one of the B. The two sources of commer-cially available type A subtypes are Botox (Al-lergan, Irvine, Calif.) and Dysport (SpeywoodPharmaceuticals, Maidenhead, England; In-amed, Santa Barbara, Calif.). Botox is usedmost often in the United States. Botox is two tofour times as effective in similar-unit doses asDysport, which is why it is available in smallervials (100-U vials for Botox versus 500-U vialsfor Dysport). Myobloc (Elan Pharmaceuticals,South San Francisco, Calif.) is derived from thebotulinum toxin B subtype, and is far less po-tent per unit dose, in general, than the A sub-type (though the bioequivalency formulationhas yet to be established). Although all agentshave comparable effects, they vary in severalways, including local discomfort with injection,onset of action, and duration of effects.

All forms of commercially available botuli-num toxin are fragile and should be reconsti-tuted and administered in a specific way tooptimize drug potency.5 The manufacturer ofBotox (Allergan) distributes the vials contain-ing 100 U of freeze-dried crystalline toxin, 0.9mg of sodium chloride, and 0.5 mg of humanalbumin in an environment of �5°C. Reconsti-tution of the dehydrated toxin should be per-formed with care. We prefer to use nonbacte-riostatic saline; however, some preferpreserved saline solution with 0.9% benzyl al-cohol to decrease potential contamination dur-ing storage of the reconstituted vial. When re-constituting the toxin, great care must be takento avoid turbulence and agitation when addingthe saline or when shaking the bottle; bothactions can lead to foaming, which can lead topossible denaturation and subsequent clinicalineffectiveness. Using a larger-gauge needle(such as an 18-gauge needle) for reconstitu-tion, or even breaking the vacuum seal by re-moving the rubber stopper, can help to limitturbulence. Alcohol, used either on the vial

cap or on the patient’s skin, should be allowedto evaporate completely before use of thetoxin, because it can inactivate the toxin, aswell.52,61,62

Although the vial can be reconstituted to adilution of 8 ml/100 U, we prefer a dilutionwith 4 cc of saline to yield a concentration of2.5 U/0.1 ml. The reduced volume may limitthe potential for possible unwanted diffusionof the toxin to surrounding areas. However,precise application is the most important pa-rameter to reduce side effects.52,62

The reconstituted toxin must be stored inthe refrigerator. Although the manufacturerrecommends use within 4 hours, some havereported effectiveness up to 30 days after re-constitution.61 Others have shown a significantloss of efficacy after 3 to 7 days.63 Bacterialcolonization of the solution must be taken intoaccount with long storage times, especially ifnonbacteriostatic saline is used as the reconsti-tuting agent. Freezing the reconstituted toxinshould be avoided, because this substantiallydecreases the efficacy of the toxin.

TECHNIQUE OF ADMINISTRATION

As with any medical procedure, informedconsent should be obtained by the physician.The patient should avoid all medications thatcan predispose to bleeding or coagulationproblems for 10 to 14 days before treatment,because this will lead to more ecchymosis afterinjection. Ice (before or after) and/or topicalanesthetic agents are used to lessen patientdiscomfort. Furthermore, the use of small-gauge needles (30 gauge) not only helps makethe treatment more tolerable but also reducesthe potential for ecchymosis, especially in thelateral canthal area.

Accurate injection of small volumes of prop-erly concentrated solution is preferred, as hasbeen discussed. It is important to isolate themuscle to be treated (by voluntary muscle con-traction and nondominant-hand palpation), toavoid inadvertent injection and undesired pa-ralysis. Electromyographic guidance has beenused for those muscles that cannot be readilyappreciated by visualization or palpation, but itis generally not necessary in clinical practice.An electromyogram can also be used to analyzethe muscle function in those patients who havebeen treated but who have not shown the de-sired or expected effect.64,65 This may helpeliminate one of the variables that could beliable for treatment failure. Electromyographic

178S PLASTIC AND RECONSTRUCTIVE SURGERY, October Supplement 2003

studies have shown that the toxin can spread bydiffusion to an area up to 3 cm or more fromthe injection site,66,67 so accurate intramuscularinjection, preferably into the muscle belly it-self, is recommended in most cases (Fig. 1).Deep massage may affect the treated area, andcould result in unwanted spread of toxin.

CLINICAL APPLICATIONS

Although botulinum toxin has many clinicalapplications, this article will specifically addressits cosmetic uses in facial rejuvenation, includ-ing its effects on the effacement of rhytides andits role in cosmetic facial reshaping. Both usesrequire an inherent knowledge base of theunderlying muscles of facial expression.

Upper Third of the Face

Four muscles are primarily responsible forthe primary dynamic rhytides of the upperthird of the face: the frontalis, the procerus,the corrugator supercilii, and the orbicularisoculi muscles. The procerus, corrugator, andorbicularis all serve to depress the eyebrow atdifferent regions along its length, whereas thefrontalis acts to elevate the brow. Each of thesemuscles has different effects, either alone or incombination, to produce overlying rhytides(Table I).

Although exact amounts of toxin to be usedper area can vary, the underlying principle isthat the more mass the target muscle has, thehigher the dose required to obtain the desiredeffect. Therefore, in general, the more bulkycorrugator muscle requires more toxin thanthe thinner orbicularis. Furthermore, the doseis also dependent on sex (males generally re-

quire more secondary to increased musclemass), prior exposure, and time interval sincethe last injection.

Forehead. Effacement of forehead rhytidescan be accomplished by first marking the rhyt-ides with a marker during active contractionand subsequently injecting along the demar-cated line every 1 or 1.5 cm, for a total of 10 to20 U (Fig. 2). Alternatively, patients can beasked to raise their forehead and eyebrowswhile injection is given to these areas withoutthe need for marking. However, in men withthicker frontalis and corrugator muscles andmore prominent rhytides, an additional 10 to15 U may be required. Most clinicians avoidinjection within 1 cm superior to the eyebrow toreduce the chance for migration and diffusionof the toxin that may affect the upper eyelidelevators.68 We prefer more superficial injec-tions in this area, because deeper injections(near the periosteum) can lead to brow ptosis.

Occasionally, chemodenervation of the fron-talis muscle may unmask previously undiag-nosed upper eyelid ptosis that had been com-pensated for by the frontalis. Therefore,evaluation of this potential situation should beperformed before treatment (having the pa-tient look forward in repose and removing thefrontalis contribution), and its possibilityshould be discussed with the patient. Further-more, overly aggressive injection into the fron-talis can also lead to unopposed brow depres-sor function with resultant brow ptosis, whichcan be highly unaesthetic. Treatment of such acomplication may involve chemodenervatingthe opposing procerus and lateral orbicularisoculi muscles.69

Procerus and corrugator. The procerus, cor-rugators, and medial orbital orbicularis oculimuscles are all, to varying degrees, responsiblefor the vertical glabellar rhytides and the hor-

FIG. 1. Botulinum toxin can spread to an area up to 3 cmfrom the injection site.

TABLE IMuscles of the Upper Third of the Face Primarily

Responsible for Rhytides

Muscle FunctionCorresponding

Rhytides

Frontalis Brow elevator Horizontalforehead lines

Procerus Medial browdepressor

Transverseglabellar lines

Corrugator supercilii Brow depressor Vertical glabellarlines

Orbicularis oculi Brow depressor Crow’s feet (lateralcanthal)

Vol. 112, No. 5 Supplement / COSMETIC USE OF BOTULINUM TOXIN 179S

izontal rhytides at the bridge of the nose. Theprocerus is prominent between the medial mar-gins of each eyebrow, whereas the corrugatorslie more laterally. To chemodenervate this area,several injection sites are used.

Some plastic surgeons prefer the hourglasstechnique shown in Figure 2, left, and Figure 3.In this technique, the waist, or narrowest por-tion of the hourglass, is a single point justinferior to a line joining the medial brow mar-gins. This point receives 2 or 3 U of toxin. Theinferior (wider) aspect of the hourglass con-sists of two points just lateral to the dorsal

aesthetic lines along a plane just inferior to themedial canthi. These points receive approxi-mately 2 U per site and are used to chemod-enervate the proximal nasalis muscle to pre-vent the “bunny” look. The superior portion ofthe hourglass is formed by points just above themedial brow (in line with the medial canthus)that course along the superior orbital rim.Here, 4 or 5 U of toxin is injected on each side.Of course, these doses can be adjusted depend-ing on the prominence of the rhytides and themass of the underlying muscles.

Orbicularis oculi. The orbicularis oculi hasthree parts: the outer orbital part, the innerpalpebral portion, and the medial lacrimal part.The medial aspect serves as a brow depressorand can be addressed as above. Hyperfunc-tional movement and resultant hypertrophy ofthe lateral fibers are primarily responsible forrhytides that radiate axially away from the lat-eral canthus, forming what is known as crow’sfeet. Because this muscle is the underlying eti-ology for the rhytides, chemodenervation is theoptimal treatment rather than other modalitiessuch as excisional techniques, resurfacing, orsoft-tissue augmentation. However, because theorbicularis function is necessary to close theocular aperture, complete paralysis of this mus-cle is unreasonable. Rather, weakness of themuscle is the objective.52

It is important to identify and locate theareas of orbicularis to be treated. This is doneby having the patient actively squint (Fig. 4).The toxin is then injected in three or fourareas.70,71 It is important to use a high concen-tration (low volume) of Botox68,71 and injectslowly69 to prevent potential diffusion to un-

FIG. 3. The “hourglass” outline of anticipated injectionsites of the procerus and corrugators.

FIG. 2. (Left) Forehead rhytides in repose with anticipated injection sites demarcated. (Right) Active frontalis contraction canguide the demarcation of the anticipated injection sites.


wanted areas. The areas of injection extendfrom just inferior to the lateral edge of theeyebrow, down the lateral aspect of the lateralorbital rim, to a point lateral to the infraorbitalrim. Two or three units of toxin are injected ateach point. To avoid complications, it is impor-tant to restrict injection to these areas. If theinjection site is too medial, diffusion of thetoxin can affect the medial orbital portion ofthe orbicularis oculi muscle, resulting in lowerlid ptosis (retraction and/or ectropion), stra-bismus, epiphora, and diplopia, as well as thepossibility of potentiating dry eye symptoms.67Injecting more inferiorly can result in un-wanted paralysis of the zygomaticus major, re-sulting in lip ptosis and an asymmetricsmile.57,67 Injecting more superiorly can resultin paralysis of the inferior fibers of the frontalismuscle, resulting in eyebrow ptosis. Further-

more, many practitioners inject the perioculararea in a subcutaneous rather than intramus-cular plane to allow for treatment of a largerarea with fewer injection sites.52,72,73 The thin-ner orbicularis seems to respond adequately tothis more superficial injection. Because there isa rich vascular plexus in this area, more injec-tion sites can result in more unwantedecchymosis.

Eyebrow. Mild to moderate brow ptosis can bemanaged in selected patients with chemodener-vation of the brow depressors.52,68,69,74–76 This tech-nique can also be used as a treatment for inad-vertent paralysis of the inferior frontalis fibers, aspreviously described. The result is, in effect, a“chemical brow lift,” although it usually only re-sults in approximately 1 or 2 mm of elevation.69More significant ptosis is reserved for surgicaltreatment.

FIG. 4. (Above, left) Crow’s feet in anteroposterior view. (Above, right) Accentuation of crow’s feet with active contraction(squinting) of the orbicularis. (Below, left) Oblique view. (Below, right) Oblique view with active contraction. The dots delineatethe sites of anticipated injection.


The brow contour can also be reshaped us-ing chemodenervation, which can result in anapparent improvement of the brow position.For instance, the medial frontalis muscle canbe chemodenervated with concurrent treat-ment to the lateral brow depressor. This com-bination can give the illusion of a chemicalbrow lift by affecting the relative positions ofthe medial and lateral aspects of the brow,despite minimal absolute changes.

Middle Third of the Face

In general, it is important to distinguish be-tween dynamic rhytides caused by underlyingmuscle hyperkinetics and static rhytides result-ing from the natural process of aging (collagenloss and photodamage). This differenceshould be explained to the patient to reducethe incidence of patient dissatisfaction, be-cause chemodenervation will not amelioratestatic rhytides. Because static rhytides are morecommon in the midface, accurate diagnosisand proper counseling are imperative for asuccessful outcome. Furthermore, chemoden-ervation of the mimetic muscles causing dy-namic rhytides in this region of the face is donewith great caution, because functional deficitsin this region are common.

Nose. In patients with severe nasal flaringresulting in increased columellar show, the alarportion of the nasalis muscle has been chemo-denervated to reduce the flaring. Approxi-mately 5 U of toxin is injected per side wherethe nasalis is visible on active nostril flaring. Thenostril geometry itself is not altered with thistreatment, because its configuration is basedmore on the lateral crus than on the nasalis.

Nasolabial fold. In 1992, Pessa and Brown77performed a cadaver study to determine therelative influences various mimetic muscles hadon the nasolabial fold. They found that thelevator labii superioris alaeque nasi had the

most prominent effect on the medial nasolabialfold, whereas the levator labii superioris had thegreatest influence on the middle of the fold. Onthe basis of this information, Kane78 tried che-modenervation of the levator labii superiorisalaeque nasi to efface the medial nasolabialfold. He found that the greatest improvement(and satisfaction) was in those people with “ca-nine” smiles (according to Rubin’s classifica-tion79) with high central lip elevations and largeresultant incisor show. Still, some patients feltthat the tradeoff of alterations in their smilemechanics was not worth the aesthetic improve-ment, even in this subgroup. Others have triedchemodenervation of these mimetic musclesand have also found lengthening of the upperlip and decreased tooth show.80 The alterationof smile mechanics can be especially dramaticin the instance of zygomatic major muscle che-modenervation, because this muscle is respon-sible for the predominant smile morphology inpopulation studies.79 As a result, rejuvenation ofthis area is best accomplished by other modal-ities, such as rhytidectomy and collagen or fatinjection.

Lower Third of the Face

Mouth and lips. The main muscles of thisregion are the orbicularis oris, depressor angulioris, and mentalis. As with the other regions ofthe face, it is imperative to distinguish betweendynamic rhytides resulting from functional un-derlying muscle hyperkinetics and static rhyt-ides resulting from the natural process of agingand atrophy. The small, vertically oriented rhyt-ides of the upper lip can, in some instances, betreated by chemodenervation of the orbicularisoris.52 To differentiate functional rhytides fromsenescent changes, have the patient activelypurse the lips. This maneuver will exacerbatethe rhytides if they are functional in nature. Totreat this area, the most prominent rhytides are

FIG. 5. Perioral rhytides in repose and with active contraction (pursing of the lips). The dots indicate areas of anticipatedinjection sites.


marked, and toxin is injected in a subcutaneousplane on both sides of the rhytides (Fig. 5).Each site should receive approximately 0.5 to 1U of toxin. Again, overly aggressive injection,either in depth or amount, can result in flaccidparalysis of the orbicularis with resultant oralincompetence and lip asymmetry.

If the oral commissures are persistentlydownward sloping from an overactive depres-sor anguli oris muscle, or if the patient hasprominent marionette lines or labiomentalcreases, chemodenervation may help. Themuscles are located by having the patient ac-tively frown. The depressors are marked andsubsequently injected with 2 or 3 U of toxin.The location of the intramuscular injectionshould be approximately 1 cm lateral and 1 cminferior to the angle of the mouth. Orbicularisincompetence can result if these margins areviolated. A reduced amount of lower toothshow will be variably induced with the treat-ment of the lip depressors. The preoperativeassessment will determine the individual ap-propriateness of this approach.

Mentalis. Occasionally, topographic chin ir-regularities (such as cobblestoning) can be seenas a result of a hyperkinetic mentalis muscle. Tosuccessfully chemodenervate this area, a total of10 U of toxin is subcutaneously injected (inseveral aliquots) into the affected area, makingsure to stay at least 1 cm inferior to the mentalsulcus. This technique will help avoid oral in-competence due to inadvertent orbicularis orisparalysis from toxin migration.

The Neck

The aesthetic appearance of the neck is sig-nificantly affected by age and by a hyperkineticunderlying platysma. Although lipodystrophyand static rhytides are not amenable to treat-ment with botulinum toxin, vertical musclebanding and horizontal neck rhytides can beameliorated by chemodenervation. These

changes are thought to be secondary to a hy-perkinetic platysma with concomitant loss oftone.81,82

Chemodenervation of the neck can be per-formed rapidly, safely, and repeatedly, withpredictable results. In general, the neck re-quires larger doses than the face, and the onsetof action of toxin is relatively faster. Matarassoet al. have developed a modified classificationsystem for age-related neck degeneration (Ta-ble II).59,83 This system, in turn, is helpful indetermining the dosage of botulinum toxinrequired to chemodenervate the platysma (Ta-ble III).59 It is also helpful in estimating thepretreatment prediction of positive outcome,with the best results found in category II andIII necks (98.5 percent good to excellent re-sults).59 The effect usually lasts for 3 to 6months. If suboptimal results are obtained af-ter the first treatment, reinjection can be per-formed after 14 days.

The technique of treatment is as follows:obtain informed consent; cleanse skin with al-cohol; in seated position, have patient force-fully grimace (Fig. 6); identify and isolate theplatysmal bands with the nondominant hand(Fig. 7); inject 2.5 to 5 U of toxin into themuscle belly at 1-cm to 1.5-cm intervals alongthe band, including down to where the musclemeets the clavicle, when present.

TABLE IIClassification of Age-Related Neck Degeneration*

CategoryHorizontal Neck

Rhytides Platysmal Bands Skin LaxitySubcutaneous/

Submuscular Fat

I Minimal Detectable with minimal neck contracture Minimal VariableII Mild Thin, mild flaccidity Mild Variable

III Moderate Thick, moderate flaccidity Moderate VariableIV Deep Heavy, severe flaccidity and hypertrophy at rest Severe Variable

* System is a modified version of that of Brant and Bellman (Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol. Surg. 24: 1232, 1998). The systemis useful in determining dosage requirements; moreover, it correlates with the prediction of degree of success after treatment. Note: Submandibular gland ptosis cancontribute to the aging neck. Reprinted from Maratasso, A., Matarasso, L. S., Brandt, F. S., and Bellman, B. Botulinum A exotoxin for the management of platysmabands. Plast. Reconstr. Surg. 103: 645, 1999.

TABLE IIICorrelation of Category of Aging Neck Deformity with

Suggested Dose of Botulinum A Exotoxin

Category of NeckDegeneration Dose Range*

I 30–50 UII 30–75 U

III 50–100 UIV 50–250 U

* Subject to change based on the strength of the toxin and individualvariations. Reprinted from Maratasso, A., Matarasso, L. S., Brandt, F. S., andBellman, B. Botulinum A exotoxin for the management of platysma bands.Plast. Reconstr. Surg. 103: 645, 1999.


It is important to confine the injection oftoxin to the superficial platysma, rather thanthe deeper musculature, because weakness ofthe neck flexors and dysphagia have been re-ported with injection into the muscles of de-glutition.68 Meticulous attention should be di-rected to the thinner necks of women to avoidthis potential complication.

COMPLICATIONS

Although botulinum toxin is relatively safe ifused properly, it must be remembered that it isone of the deadliest toxins known to humans.Contraindications to treatment are pregnancy,lactation, allergic reaction to human albumin,history of neuromuscular disorders (myasthe-nia gravis, Eaton-Lambert syndrome, amyotro-

phic lateral sclerosis), concomitant use of cer-tain medications known to potentiate theeffects of botulinum toxin (penicillamine, qui-nine, calcium channel blockers, and aminogly-cosides), and psychological instability.5

Complications can be subdivided into threecategories: local, regional, and systemic. Themost common local side effect is pain at theinjection site. Other local effects can includeerythema, rash, ecchymosis, edema, hyperes-thesia, and hematoma. These can be mini-mized by slow injection rates, topical anesthet-ics, ice, and avoidance of treatment in patientscurrently taking nonsteroidal anti-inflamma-tory drugs.

Regional complications, such as unwantedweakness or paralysis of muscles adjacent to thepoint of injection, have been previously de-scribed. Upper lid ptosis from levator paralysis,brow ptosis from frontalis dysfunction, lipasymmetry from zygomaticus major paralysis,and dysphagia from deep neck muscle weak-ness all result from migration and diffusion oftoxin. To minimize these unwanted results,landmarks and boundaries to injection sitesand the depth of injection must be adhered to.Mild to moderate upper eyelid ptosis can beeffectively treated until the lid ptosis resolveswith the use of topical antihistamine or decon-gestant agents (eye drops) that have the adren-ergic side effect of contracting the Müller mus-cle (Naphcon A eye drops; Alcon, Inc., FortWorth, Texas).52,62,74

In rare instances, systemic reaction has been

FIG. 7. Identification, isolation, and injection of theplatysmal bands.

FIG. 6. (Left) Platysmal banding in repose. (Right) Platysmal banding accentuated with activecontraction.


described. As mentioned previously, those withallergies to human albumin should avoid thisproduct altogether, because human albumin isan ingredient. Reactions such as fatigue, mal-aise, distant rashes, and nausea can occur, butare rare.5 There are two cases reports of severesystemic reactions. One report describes lowerlimb anaphylaxis after injection for foot dysto-nias,84 and the other details a case of respira-tory arrest after treatment for muscle spastici-ty.85 It should also be mentioned thatoccasionally antitoxin antibodies can develop,rendering the toxin inactive.5 This effect ismore likely to occur if higher-than-recom-mended doses are given or when treatmentsare performed more frequently than sug-gested.4,86,87

OTHER APPLICATIONS

Other medical conditions have been success-fully managed by harnessing the effects of bot-ulinum toxin. The following conditions havedemonstrated improvement with chemodener-vation: benign essential blepharospasm, cervi-cal dystonias (including torticollis), generalspasticity, strabismus, vaginismus, postrhytidec-tomy synkinesis after partial facial nerve palsy,cranial nerve disorders (including hemifacialspasm), Frey’s syndrome (gustatory sweating),excessive perspiration, migraine headaches,stress headaches, Hirschsprung disease, analfissures, and esophageal motility disorders.

SUMMARY

The chemodenervating effect of botulinumtoxin has been successfully harvested and ap-plied to the field of cosmetic plastic surgery.Treatment is safe, effective, predictable, mini-mally invasive, and repeatable. Its temporaryeffect on the hyperkinetic muscles of the faceand neck, with subsequent ameliorating effectsof the overlying rhytides, makes botulinumtoxin a useful adjunctive therapy in aestheticrejuvenation. If performed by qualified individ-uals on carefully selected patients, this treat-ment modality may offer a viable nonsurgicalchoice for rejuvenation of the aging face.

Rod J. Rohrich, M.D.Department of Plastic SurgeryUniversity of Texas Southwestern Medical Center5323 Harry Hines Boulevard, E7.212Dallas, Texas [email protected]

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Self-Assessment Examination follows onthe next page.


Self-Assessment Examination

The Cosmetic Use of Botulinum Toxinby Rod J. Rohrich, M.D., Jeffrey E. Janis, M.D., Steven Fagien, M.D., and James M. Stuzin, M.D.

1. REGARDING THE DOSE AND DURATION OF ACTION, CHEMODENERVATION BY BOTULINUM TOXIN IS:A) Dose independent and permanentB) Dose independent and temporaryC) Dose dependent and permanentD) Dose dependent and temporaryE) None of the above

2. WHICH OF THE FOLLOWING IS RECOMMENDED FOR THE SAFE HANDLING OF BOTULINUM TOXINTYPE A?A) Keep vial frozen before reconstitutionB) Use sterile water for reconstitutionC) Shake vial well after reconstitutionD) Keep reconstituted solution at room temperatureE) Discard unused solution after 30 days

3. IN ORDER TO MINIMIZE ADVERSE OR UNTOWARD SIDE EFFECTS WHEN USING BOTULINUM TOXINTYPE A:A) Use the most dilute concentration possibleB) Use large-bore needlesC) Use nonsteroidal anti-inflammatory drugs preoperatively to reduce inflammationD) Massage area after injectionE) Apply ice to area after injection

4. STATIC RHYTIDES CAN BE TREATED WITH THE SAME EFFECTIVENESS AS DYNAMIC RHYTIDES:A) TrueB) False

5. OF THE FOLLOWING, WHICH IS THE MOST SIGNIFICANT POSSIBLE COMPLICATION OF BOTULINUMTOXIN TYPE A USED IN THE SUPRAORBITAL REGION?A) Pain on injectionB) EcchymosisC) HematomaD) BlepharoptosisE) Brow ptosis

To complete the examination for CME credit, turn to page 192S for instructions and the response form.

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