Botulinum Toxins in Clinical Aesthetic Practice 3E, Volume Two

Functional Anatomy and Injection Techniques

Anthony V Benedetto, Anthony V Benedetto

• Editorial: CRC Press
• Año: 2017
• ISBN:
  9781351396325
• Edición: 3
• Categoría: Médecine
• Categoría: Théorie, pratique et référence de la médecine

This bestselling guide to the complexities of botulinum toxins has now been extensively revised, updated, and expanded. Now in two volumes, Volume 1 examines clinical adaptations in the toxins in use today, use with other injectables, use for other parts of the body and other indications, and legal aspects, while Volume 2 documents in detail the functional anatomy and injection techniques for the face, neck, and upper chest. No practitioner of aesthetic medicine will want to be without this comprehensive and authoritative guide from the international experts.

13

Cosmetic uses of botulinum toxin A in the upper face

Anthony V. Benedetto

Introduction

In the United States, injections of botulinum neurotoxin (BoNT) to diminish horizontal forehead wrinkle lines, glabellar (central brow) frown lines and lateral canthal rhytides (crow’s feet) are the only cosmetic and aesthetic indications approved by the Food and Drug Administration (FDA) in the United States of America (USA).1–3 Injecting BoNT for cosmetic purposes in any other part of the face or body is not approved in the United States (US) by the FDA and therefore is considered off label use.1–3 It remains to be seen whether the FDA and other governmental regulatory agencies of other countries will ever approve every single indication for which the BoNTs have proven to be effective in clinical practice. The fact remains that BoNTs are extremely reliable, nontoxic, and safe.1–6 BoNTs provide reproducible results when administered as prescribed. Consequently, BoNTs have now become a major component of the armamentarium of any physician who practices aesthetic medicine in any capacity and who wants to produce the best cosmetic results for their patients.

In the early 1980s, botulinum neurotoxin serotype A (BoNT-A), known at that time as Oculinum™, was found to be effective for the treatment of strabismus in humans as an alternative to surgery.7 Soon thereafter, Oculinum™ was acquired by Allergan, Inc. and renamed BOTOX®. In 1989, BOTOX® was approved by the FDA for the therapeutic treatment of strabismus and blepharospasm.7 By 2000, BOTOX® was approved by the FDA for the therapeutic treatment of cervical dystonia. In April 2002, the FDA approved BOTOX® for the cosmetic treatment of glabellar frown lines. This resulted in the manufacturer’s redesignation of the additional brand name of BOTOX® Cosmetic.1 Both BOTOX® and BOTOX® Cosmetic are exactly the same product: they contain the same active ingredient in the same formulation, are manufactured by identical methods, and are only distributed under different names for different labeled indications and usage. BOTOX® is to be used for therapeutic purposes, whereas BOTOX® Cosmetic is to be used for cosmetic purposes.1,8

Subsequently, new and different formulations of BoNT-A other than BOTOX® and BOTOX® Cosmetic were approved for use in the US for both therapeutic and cosmetic purposes. The first of these was DYSPORT®,2,9–11 which was approved by the FDA in May 2009 (see Chapter 5 by Monheit and Highsmith). In July 2011, XEOMIN®, a non-complexed BoNT-A was approved by the FDA for therapeutic and cosmetic purposes3,12–14 (see Chapter 3 by Juergen Frevert).

To distinguish the current and future different formulations of BoNT from one another without mentioning their trade names, the FDA has assigned nonproprietary names, a type of “generic” name, to the different formulations of the currently approved BoNTs. (OnaBTX-A) was assigned to BOTOX® and BOTOX® Cosmetic, also known as Vistabel® in certain countries in Europe, and Vistabex® in Italy. AbobotulinumtoxinA (AboBTX-A) was assigned to DYSPORT®, also known as Azzalure® in Europe and Reloxin® elsewhere. IncobotulinumtoxinA (IncoBTX-A) was assigned to XEOMIN®, otherwise known as XEOMEEN® in Belgium and Bocouture® in Europe and elsewhere. Botulinum neurotoxin type B (BoNT-B) known as Myobloc® in the United States and Neurobloc® in Europe was given the designation of RimabotulinumtoxinB (RimaBTX-B) (see Chapter 5). Other BoNTs currently available for use in other parts of the world are discussed in Chapter 6 by Andy Pickett.

Chapters 13 through 15 discuss cosmetic injections of BoNT for the face and body. It is of particular importance to understand that in order to avoid ambiguity and confusion with the injection of appropriate and effective doses of BoNT, any reference to BoNT-A in these three chapters will indicate specifically BOTOX® Cosmetic and explicitly onabotulinumtoxinA or OnaBTX-A. The reason for this is not preferential usage by the author, but because OnaBTX-A was the first BoNT-A to be used for cosmetic purposes worldwide, and for many years a multitude of patients have been treated with OnaBTX-A before any of the other BoNT-As were available. Consequently, most of the patients illustrated in these next three chapters were treated with OnaBTX-A with the preferred dosages indicated. Therefore, for the sake of clarity and uniformity, all dosage units specified throughout Chapters 13 through 15 are expressed in units of OnaBTX-A.

Some may criticize the “cookbook” approach to Chapters 13 through 15. This systematic detailing of why, where, and how much OnaBTX-A to inject in a particular area of the face and body, however, is necessary to understand when correcting a certain aesthetic problem, and, therefore, was done intentionally. Moreover, it is important to note that the face is the only area of the body where there is no deep subcutaneous membranous fascia beneath the skin, thus allowing slips of muscle fibers that are attached to the facial skeleton at their origin to insert directly into the undersurface of the skin. But not all facial muscles have their origins attached to bone. Some arise from aponeuroses, but then they still insert onto the undersurface of the skin. Consequently, when these muscles contract, they move the skin of the face, producing folds and wrinkles always in a perpendicular orientation to the direction of muscle contraction. Nowhere else in the body are there similar types of muscles that contract voluntarily or involuntarily, pulling on the skin and expressing an emotion.

The face can be divided topographically into three segments using anatomical and cosmetic unit boundaries: the upper, mid, and lower part of the face. In these segments of the face there are either single or multiple muscles, that when contracted, move mostly in one direction. Depending on their location on the face and the anatomic position of their fibers, these mimetic muscles can move the skin in an upward, oblique, or downward direction. For example, this allows one to either raise or lower the eyebrows, smile or frown, open or shut the eyes, and so on. This difference in the direction of skin movement is done by muscles in a complementary, opposing fashion, that is, by elevating (levator) or lowering (depressor) muscles. These competing movements by agonistic or antagonistic muscles contracting intentionally or unintentionally cause horizontal, radial, or vertical wrinkling of the face. Consequently, nonverbal communication can be expressed with the slightest contraction of one or a combination of facial muscles (hence the designation “mimetic facial muscles”).

The reader must never lose sight of the fact that every single individual patient is different and he or she should never be treated in an identical fashion without justification. These Chapters 13 through 15 strive to provide both the learning and experienced physician injector, the rationale for why and how a patient should be treated with a particular dose of OnaBTX-A in one area or...