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Botulinum Toxin in Aesthetic Medicine. Bearbeitet von. Mauricio de Maio, Berthold Rzany. 1st ed. Corr. 2nd printing Buch. xix, S. Hardcover. Sitemap. [PDF Free Download] Botulinum Toxin in Aesthetic Medicine Full Online - by Mauricio de Maio. Botulinum Toxin in Aesthetic Medicine. The use of botulinum toxin A (BoNT-A) in aesthetic medicine has increased markedly since the first applications in this setting during the mids. Current .
If required, a second line of injections can be placed above the first with the addition of two injection points at F2 and F3, and subcutaneous injection of 1 U of botulinum toxin at each point.
Botulinum Toxin A In Aesthetic Medicine – 2nd Edition
Tendency to develop Mephisto sign The so-called Mephisto sign occurs in some patients when lateral movement of the frontalis remains after treatment and produces visible wrinkles. It is more common when treatment of the forehead is restricted to the area between the midpupillary lines. Women with strong lateral frontalis fibers should receive 1 U intramuscularly at F6 and F7 and 1 U subcutaneously at points F9 and F Palpebral weakness Upper eyelid ptosis may occur when treatment of the frontalis muscle unmasks subtle pre-existing weakness of the levator palpebrae superioris muscle.
Botulinum toxin product labels recommend evaluation of the upper eyelid, especially in patients with a history of glabellar trauma or surgery, for the presence of levator palpebra muscle separation or weakness. V-shaped frontalis The frontalis may form either a uniform band across the forehead or be V-shaped with a relative absence of fibers medially.
Women with hyperkinetic frontalis Average-size forehead Treatment is with the same pattern of intramuscular injection as for women with a kinetic frontalis F5 to F8 , but using the higher end of the dose range 2 U per injection point.
High forehead In the first row of injections, treatment is with 2 U intramuscularly at each of points F5 to F8.
Women with a high forehead can receive a second line of injections placed above the first. However, in those with a hyperkinetic frontalis, the two additional injection points at F2 and F3 are injected intramuscularly rather than subcutaneously with 1 U of botulinum toxin at each point.
Tendency to develop Mephisto sign Treatment is with 2 U of toxin injected intramuscularly at injection sites F6 and F7. Women with hypertonic frontalis Average-size forehead Hypertonic patients are difficult to treat, and the limitations of botulinum toxin treatment should be explained beforehand.
The recommended treatment protocol is 1 U of botulinum toxin subcutaneously at sites F5 and F8, and 1 U intramuscularly at sites F6 and F7. Hypertonic patients are particularly susceptible to brow ptosis, and injection in the lateral limit of the frontalis should be avoided. High forehead Treatment is as for women with an average-size forehead with the recommendation that patients are evaluated after several days at the follow-up appointment to determine if further treatment is necessary.
Other forehead presentations These are uncommon in women with a hypertonic frontalis, and the details of their treatment are presented in Table 1. Men with kinetic frontalis Average-size forehead For men with regular frontalis contractions, dynamic forehead wrinkles, and an average size forehead, the group recommends intramuscular injection at four injection points across the midline of the forehead F5 to F8 with 2 U of botulinum toxin per point.
Prominent forehead It is important not to accentuate a prominent forehead due to a receding hairline or shaved head. Smoothing out the entire forehead or leaving muscle activity above the level of the normal hairline would draw attention to the upper third of the face. In addition to intramuscular injection of 2 U at points F5 to F8, these men can also be treated with additional intramuscular injection of 1 U at points F1 and F4 1 cm below the muscle attachment.
Tendency to develop Mephisto sign In addition to intramuscular injection of 2 U at points F5 to F8, 1 U of toxin can be injected intramuscularly at each of injection sites F9 and F12 coinciding with the point of maximum contraction.
Palpebral weakness Men with palpebral weakness should receive intramuscular injection of 2 U at points F5 and F8 plus 3 U at points F6 and F7. Prominent forehead A second line of injections can be placed above the first as in men with a kinetic frontalis, but a higher dose may be used.
V-shaped frontalis Standard treatment is with intramuscular injection of 2 U at points F5 to F8. Short forehead Men with a short forehead and hyperkinetic frontalis receive the standard treatment of 2 U intramuscularly at each of points F5 to F8. Lateral superciliary wrinkles Prominent lateral superciliary wrinkles will require additional injections in the lateral frontalis.
Men with hypertonic frontalis Average-size forehead The limitations of botulinum toxin treatment in these patients should be explained before starting the treatment to avoid disappointment.
The recommended treatment protocol is 1 U of botulinum toxin intramuscularly at sites F5 to F8. Prominent forehead Two rows of injection are used.
In the first row, toxin is administered intramuscularly as 1 U at each of points F5 to F8. When performing this treatment, the brow depressor muscles corrugator supercilii, procerus, depressor supercilii, and superolateral portion of the orbicularis oculi should be treated at the same time. Short forehead Men with a short forehead and hypertonic frontalis should be treated with intramuscular injection of 1 U at each of points F5 to F8.
Other forehead presentations The Mephisto sign and V-shaped frontalis are rare in men with a hypertonic frontalis, and the details of their treatment are presented in Table 2.
A number of consensus documents have been published to assist physicians on the use of botulinum toxin in aesthetic medicine. The recommendations were developed on the premise that no single injection protocol can suit all patients.
However, few studies in the literature account for differences in facial anatomy and muscle tone when evaluating treatment with botulinum toxin. Sexual dimorphism in facial anatomy and cutaneous physiology is well documented, yet these differences are rarely accounted for in clinical practice.
Such anatomical variations between genders result in differences in aging and consequently in how individuals should be treated. For an optimal aesthetic outcome, each patient should undergo a static and dynamic assessment of muscle position, mass, and functional status prior to treatment. In the current consensus, muscle tone is divided into kinetic, hyperkinetic, and hypertonic, and each must be treated differently for optimal results.
Careful observation of the extent of dynamic movement of the skin will identify areas of stronger or weaker muscle contraction. In this way, the physician can determine why certain wrinkles are formed and which muscles are creating them. This information is needed to balance the effects of opposing muscles and minimize the risk of unwanted outcomes. The static and dynamic evaluation may also identify other more subtle variations in facial musculature that should be considered during the planning of an effective botulinum toxin treatment regimen, such as palpebral weakness, compensatory muscle use, and facial asymmetry.
The dynamic assessment is therefore essential to optimize the dose and injection technique for each patient. It is hoped that the current consensus document will be of use to a wide range of aesthetic physicians from beginners to experts.
It departs from the single template of dosing and injection points described in most consensus guidelines by tailoring treatment protocols to individual patients, which will lead to more satisfactory, natural, and individualized aesthetic outcomes.
Insert the needle perpendicular to the wrinkles and administer a superficial subcutaneous injection using a linear technique.
See Figure, Supplemental Digital Content 6, which shows the injection technique for perioral lines. Inject slowly and evenly, and massage after each injection. Do not chase superficial lines. Avoid elongation and flattening of the upper lip because of overinjection and avoid overcorrection. The total dose is 6 to 10 U of onabotulinumtoxinA, depending on severity and muscles involved. For each injection, insert the needle pointed upward to one-half of its depth; inject into the depressor septi nasi left and levator labii superioris alaeque nasi right.
Patients with a short upper lip are ideal candidates, whereas care should be exercised in patients with gummy lip and a long upper lip. Upper Lip and Lower Lip Lines Vertical lines on the upper and lower lips occur with aging and may remain after dermal filler treatment.
Insert only the needle bevel pointed upward. See Figure, Supplemental Digital Content 8, which shows the injection technique for upper lip lines. For each injection, insert the needle to the depth of the bevel, with the bevel Gummy Smile Gummy smile refers to the showing of excessive gum while smiling or laughing.
In moderate gummy smile, the levator labii superioris alaeque nasi muscle elevates and everts the upper lip, and the depressor septi nasi muscle draws the nasal tip downward and lifts the medial tubercle.
Correction of perioral lines with Ultra or Volbella. These fillers are injected at one site in each quadrant. Areas of caution: perioral vascularization branches of the upper labial artery. Treatment of gummy smile with onabotulinumtoxinA. Injections are made at three sites for moderate gummy smile yellow X and at two additional sites for severe gummy smile blue X. The symbol X indicates one-half needle depth. Treatment of upper and lower lip lines with onabotulinumtoxinA.
Injections are made at one or two sites per side. Avoid administering excessive doses, which may lead to flattening of the lips and restrict lip pursing, or injecting too close to the mouth, which may impact lip function and cause drooling. Treatment of marionette lines may be achieved with Ultra Plus or Volift. Injections are made at two sites on each side Fig. Injectors should be alert to avoid the inferior labial and sublabial arteries and veins.
Using a linear retrograde technique, deliver a superficial subcutaneous injection. Inject slowly, and deliver most of the volume to the top third of the fold while staying medial to the marionette line.
The upper injection is made by inserting the needle inferior to the modiolus and injecting slowly using a vertical column technique, in which the filler is injected as the needle is withdrawn from the deeper tissue. The jawline should be smooth from the angle of the jaw until the chin, uninterrupted by the jowl or postjowl and prejowl sulcus. Viewing this area from the front and sides is critical in assessment.
Evaluate for the Fig. Correction of marionette lines with Ultra Plus or Volift. Fillers are delivered by means of injections at two sites per side. Areas of caution: avoid the inferior labial and sublabial arteries and veins. The upper injection is made in the modiolus using a smaller volume. For the linear retrograde technique, deliver a superficial subcutaneous injection not shown.
Filler is delivered to one injection site per side Fig. Injectors should be alert to avoid the sublabial artery and vein. Deliver a superficial subcutaneous injection through a linear retrograde technique. Injections are made by means of linear retrograde technique. Alternatively, injection using a linear anterograde technique can be made if starting laterally not shown. Chin Apex A recessed chin is aesthetically undesirable; augmentation increases the anterior projection and rounding of the chin.
Each product is delivered to two to three injection sites Fig. Injectors should be alert to avoid the mental artery and vein. For the first injection, position the needle at the midline of the jawline, and aspirate before injection.
See Figure, Supplemental Digital Content 11, which shows the injection technique for augmentation of chin apex. Aspirate before injection and inject slowly. Inject slowly and deliver a supraperiosteal small bolus.
Compare symmetry before and after the injection by watching from the cephalic view. Maintain the injection in the midline and avoid chin deviation. Use two fingers to pinch the chin to avoid unwanted displacement of the filler. Massage after the injection. Deliver the other two injections in the same manner at superolateral sites on either side of the chin. Treatment of a mental crease with Ultra Plus or Volift. Fillers are delivered by means of linear retrograde or anterograde injection.
Areas of caution: avoid the sublabial artery and vein. Augmentation of the chin apex with Ultra Plus or Voluma. Both fillers are delivered by means of injections at two to three sites.
Areas of caution: avoid the mental artery and vein. Filling of the prejowl area with Ultra Plus or Voluma. Both fillers are delivered by means of a deep subcutaneous injection using a fanning technique. Areas of caution: avoid the mental artery and vein and the mental nerve. Prejowl Area The prejowl area is the triangular area from the mental foramen to the midlateral zone of the mandible Fig.
Injectors should be alert to avoid the mental artery and vein and the mental nerve. See Figure, Supplemental Digital Content 12, which shows the injection technique for filling of the prejowl area. Inject very slowly and use fingers to control the placement of the product.
Make a deep subcutaneous injection using a fanning technique to deliver filler to the distal parts of the triangular prejowl area.
Inject slowly, use fingers to control placement of the product, and exercise care with displacement of the filler over the mandibular ligament. Overcorrection lateral to the ligament may worsen the jowl area. Mandible Body and Angle The injection of fillers in this area creates a more defined jawline contour.
Injectors should be alert to palpate and avoid the facial artery, facial vein, and parotid gland. For the subcutaneous injection, pinch the skin above the mandible body and position the needle superficially to avoid the facial artery. For the subcutaneous injection, pinch the skin to avoid the facial artery. The supraperiosteal injections are delivered over the mandibular angle not shown. Aspirate before injection, and inject slowly using a linear retrograde technique. For the supraperiosteal injections, deliver one or two small boluses at the mandibular angle.
This is ideal for male patients. A subcutaneous approach is preferable for female patients. Aspirate before each injection, inject slowly, and avoid scratching the periosteum.
The treatment area is prone to development of deep hematomas, especially the site of the supraperiosteal injections. A dose of 2 to Fig. Treatment of the mandible body and angle with Ultra Plus or Voluma. Both fillers are delivered by means of a superficial subcutaneous injection over the mandible body and by supraperiosteal small-bolus injections over the mandible angle. Areas of caution: palpate and avoid the facial artery and vein, and avoid the parotid gland. Treatment of the depressor anguli oris muscle with onabotulinumtoxinA.
Injections are made at one site per side. For each injection, insert the needle to one-half its depth. Excessive dosing and medial injections may lead to paralysis of the depressor labii inferioris muscle, resulting in an asymmetrical smile. Mentalis Muscle Contraction of the mentalis muscle may lead to a cobblestone or dimpled chin, and may increase the mentolabial crease while pushing the lower lip forward.
A dose of 4 to 8 U of onabotulinumtoxinA should be delivered. See Figure, Supplemental Digital Content 15, which shows the injection technique for the mentalis muscle. Maintain the injection in the midline. Excessive lateral displacement of the needle may lead to paralysis of the depressor labii inferioris muscle, resulting in an asymmetrical smile.
Botulinum Toxin in Aesthetic Medicine: Myths and Realities
Masseter Muscle The masseter muscle elevates the mandible and is important during chewing; it may become Fig. Treatment of the mentalis muscle with onabotulinumtoxinA.
An injection is made at a midline point 0. Square symbols indicate full-needle depth. Treatment of masseteric hypertrophy with onabotulinumtoxinA. Injections are made at three sites on each side of the face. A dose of 4 to 8 U of onabotulinumtoxinA at each point should be delivered with the needle inserted perpendicular to the skin to its full depth. See Figure, Supplemental Digital Content 16, which shows the injection technique for masseteric hypertrophy.
For each injection, insert the needle perpendicular to the skin to its full depth. Shown is the injection at the apex point.
Ask the patient to clench before marking the injection site, and Fig. Injections are made at six sites on each side at one-third needle depth. Superficial and higher injections may cause asymmetry during animation. This area is prone to deep hematomas. Asian patients with severe hypertrophy may require higher doses of 40 U or more of onabotulinumtoxinA.
For each injection, insert the needle to one-third of its depth. This area is prone to bruising. Deep injections and excessive dosing may lead to impaired swallowing. Patients with a highly overactive platysma may benefit from two sessions to optimize the dosage of onabotulinumtoxinA. Platysma Bands The caudal parts of the platysma muscle are thin muscle sheets that run down the lateral neck and insert into the fascia pectoralis.
Treatment of lateral platysma bands is made at four sites per band Fig. Pinch the band to help guide the injection into the contracted muscle. Asterisks indicate one-third needle depth. Pinch the band and insert the needle to one-third of its depth. Consideration should be given to injecting the lateral bands at the first session and then reevaluating whether any medial bands need treatment. Injections in medial platysmal bands are more challenging than lateral bands; the overall dose of neurotoxin should be lower.
Although these injections can reduce the hypertonicity of medial platysmal bands, they can also lead to skin laxity. Proper patient selection is important. Ideally, these injections should be considered in patients without skin excess in this area. The OnabotulinumtoxinA Microdroplet Technique for Lower Face and Neck This technique has been previously described and is a useful adjunct for improving the appearance of the skin and contours of the lower face and neck.
This results in an improved Fig. Treatment of the platysma bands with onabotulinumtoxinA. Injections are made at four sites on each lateral band left and at three sites on each medial band right. The even distribution of these microdroplets at a superficial plane reduces the risk of difficulty in swallowing or weakness of the sternocleidomastoid muscles. The lip is one of the most challenging areas to reshape with fillers.
Comprehensive assessment of dental arches and occlusion is important to avoid improper correction. When volumizing the lips, respect the projection of the lips on the profile view and respect the ratio of lip size to chin. Rejuvenation of the neck region is also challenging, where fillers are needed for structural support of the chin and jawline and neuromodulators are needed to treat the masseter and platysma.
Clinica Dr.Clostridium botulinum and its neurotoxins: During these meetings, the group developed a series of recommendations covering the clinical history and physical evaluation of the patient as well as a muscular map of each treatment area illustrating the points of injection. Finally, hypertonic patients are those with an inability to relax specific muscles and with visible wrinkles at rest.