Cosmetic Botox Applications: General Considerations and Dosing

After studying this article, the participant should be able to: 1. Recognize facial muscle contraction direction and muscle morphology based on skin surface movements and facial rhytides. 2. Classify different muscle contraction patterns and target respectively with the recommended dosage and injection technique. 3. Apply the presented injection techniques to the patients' individual anatomy with greater precision and without affecting adjacent muscles or causing other adverse events. Facial muscular anatomy has recently gained increased attention, with new investigative methodologies and new injection techniques arising on the market. These recent advancements have increased our understanding about the functional anatomy of facial muscles and have changed the way health care professionals see and understand their interplay during various facial expressions and in determining facial shape. This new anatomical understanding of facial muscles and their interaction has resulted in superior neuromodulator treatment outcomes with fewer side effects and with increased precision. The latter is of greatest importance, as all facial muscles act as a unit and connect with each other. It is therefore paramount to target during neuromodulator treatments only the muscle responsible for the aesthetic effect desired and not other adjacent muscles, which can have different or even antagonistic effects. Conventional anatomy was previously limited to two-dimensional explanations of muscle locations without incorporating their detailed action or their three-dimensional location of extent. The "new" anatomy incorporates those novel concepts and, once understood, will help health care providers to understand better and to "read" the underlying muscular anatomy based on the wrinkle status and based on the change in skin surface landmarks based on the actions of the underlying musculature. The following article summarizes tips and tricks, pearls and pitfalls, and dos and don'ts during facial neuromodulator injections along with a guide toward adverse event management and patient outcome assessment with special focus on the underlying anatomy.

To review the surgical technique of the endoscopic subperiosteal midface lift and present our clinical outcome in 22 consecutive patients. We retrospectively evaluated the clinical outcomes of 39 endoscopic subperiosteal midface lifts in 22 consecutive patients. Of the 39 sides, 21 had a lower eye conjunctival spacer graft inserted (15 hard palate mucosal graft, 6 AlloDerm). The success of the procedure was graded based on the aesthetic and functional results. Subjective and objective assessments were made using history, examination, and photos. Results for the clinical outcome were graded as excellent, good, fair, or poor. Among the 39 sides, indications for the procedure included facial rejuvenation (41%), postblepharoplasty lower eyelid retraction (26%), eyelid retraction secondary to midfacial ptosis (15%), severe cicatricial ectropion (13%), and paralytic ectropion secondary to 7th nerve palsy (5%). The operating surgeons evaluated the clinical outcome as "excellent" in 24 sides (61%), "good" in 10 sides (26%), "fair" in 2 sides (5%), and "poor" in 3 sides (8%). The procedure was successful at increasing malar projection, improving lower eyelid fullness, and elevating the lower eyelid in cases of lower eyelid retraction. The procedure was less effective in decreasing the prominence of the deep nasolabial fold. The endoscopic subperiosteal midface lift is an effective method for elevating the midface. A more youthful appearance is achieved with the procedure, and when necessary, recruitment of anterior lamella allows elevation of the lower eyelid to correct retraction.

Advances in minor oral surgery in patients with congenital bleeding disorders

To determine patient-preferred injection sites and frequency for facial volume augmentation with nonanimal stabilized hyaluronic acid (Restylane). : The authors retrospectively reviewed the records of 145 consecutive patients who received 0.4 ml or 1.0 ml subcutaneous facial injections of Restylane. Location, amount, supplemental anesthetic, injection frequency, follow-up time, and use of botulinum toxin type A or other facial aesthetic interventions were reviewed. If recorded, patient satisfaction, revision rate, and any adverse reactions were also noted and analyzed. Median age at time of initial injection was 54 years; median follow-up was 8 months (mean 10.4 months, range 1-37 months). A total of 309 patient injections were performed (mean, 2.14 injections/patient), with 26% of patients receiving adjunctive anesthesia. Injection site frequencies among the 145 patients were nasolabial folds (72%), melolabial folds (70%), lips (51%), infraorbital rims (24%), perioral rhytids (24%), glabella (23%), malar hollows (10%), chin (8%), and other (8%). Among the 75 patients who received repeat injections, injection intervals were > or =4 months in 56 (76%) and > or =6 months in 28 (38%). Forty-four percent of patients received Botox and Restylane injections during the same office visits. Six complications included edema (2); vasovagal reaction during injection (1); ecchymosis (2); and herpes simplex virus dermatitis (1). Three revisions were performed. One patient was dissatisfied with the procedure. Patients elect to undergo Restylane injections to improve the appearance of rhytids and augment volume along infraorbital rims, malar hollows, lips, and depressed scars. Complications are minimal and easily treated.

Artículo traducido] Uso de rellenos faciales en la práctica clínica: nivel de satisfacción del paciente y visión general de las complicaciones clínicas comunes

The growing emphasis on maintaining a youthful appearance is driven by increased public awareness of the importance of good health and an attractive appearance, which going hand in hand with social development. Kobido massage is a suggested technique for enhancing the look and state of facial skin, serving as a non-surgical alternative to a facelift. The procedure employs specific manual techniques executed by a skilled specialist. This study aimed to evaluate the effectiveness of selected elements of kobido massage on improving the appearance of the skin, relaxing facial muscles, reducing their tension and improving blood and lymph circulation in the head area. The study included a group of 27 women who received 10 of the same treatments. The most frequently observed effects of the sequence of procedures were a reduction in tension and smoothing of facial skin folds, as well as a change in facial contour. The obtained results were consistent with the expectations of the majority of the participants. Kobido massage can be an effective method of improving the appearance of facial skin and may be a safe alternative to surgical lifting.

Implications of botulinum toxin injection of the brow ∗

To report our experience with protractor myectomy in patients with benign essential blepharospasm who did not respond to serial botulinum toxin injection, and to describe intra- and postoperative techniques that limited skin contracture while also providing excellent functional and cosmetic results. The medical records of patients with isolated, benign, essential blepharospasm who underwent protractor myectomy from 2005 to 2008 by a single surgeon were reviewed retrospectively. The technique entailed operating on a single eyelid during each procedure, using a complete en bloc resection of all orbicularis tissue, leaving all eyelid skin intact at the time of surgery, and placing the lid under stretch with Frost suture and applying a pressure dressing for 5-7 days. Data from 28 eyelids in 7 patients were included. Average follow-up was 21.5 months (range, 4-76 months). Of the 28 eyelids, 20 (71.4%) showed postoperative resolution of spasm, with no further need for botulinum toxin injections. In the 8 eyelids requiring further injections, the average time to injection after surgery was 194 days (range, 78-323 days), and the average number of injections was 12 (range, 2-23 injections). All but one eyelid had excellent cosmetic results, without signs of contracture; one eyelid developed postoperative skin contracture following premature removal of the Frost suture and pressure dressing because of concerns over increased intraocular pressure. In our patient cohort, this modified technique resulted in excellent cosmetic and functional results and limited postoperative skin contracture.

Full facelift through an endoscopic approach has been indicated for young individuals without significant skin excess but with mild laxity of the midface. It also has been indicated in secondary rhytidoplasty. Wide undermining of the face and neck is performed. Liposuction at submental and submandibular areas provides noticeable improvement for the neck and mandibular contour. Plication of the SMAS and platysma muscle is used to replace tissues and to regain a youthful appearance. Improved results become evident when plication is performed over the deformity. The unlikely course for the SMAS and platysma plication is to provide an aesthetic balance for the face and neck. Extracorporeal knotting is used to hold the folded muscle in position. In addition, scars are minimal and occur in areas where they cannot be seen. However, selection criteria must be followed to achieve excellent results with this procedure.

Marfan syndrome is a hereditary disease with a prevalence of 2-3 in 10,000 births, leading to a fibrillin connective tissue disorder with manifestations in the skeleton, eye, skin, dura mater and in particular the cardiovascular system. Since other syndromes demonstrate similar vascular manifestations, but therapy may differ significantly, diagnosis should be established using the revised Ghent nosology in combination with genotypic analysis in specialized Marfan centres. The formation of aortic root aneurysms with the subsequent risk of acute aortic dissection type A (AADA) or aortic rupture limits life expectancy in patients with Marfan syndrome. Therefore, prophylactic replacement of the aortic root needs to be performed before the catastrophic event of AADA can occur. The goal of surgery is the complete resection of pathological aortic tissue. This can be achieved with excellent results by using a (mechanically) valved conduit that replaces both the aortic valve and the aortic root (Bentall operation). However, the need for lifelong anticoagulation with Coumadin can be avoided using the aortic valve sparing reimplantation technique according to David. The long-term durability of the reconstructed valve is favourable, and further technical improvements may improve longevity. Although results of prospective randomised long-term studies comparing surgical techniques are lacking, the David operation has become the surgical method of choice for aortic root aneurysms, not only at the Heidelberg Marfan Centre. Replacement of the aneurysmal dilated aortic arch is performed under moderate hypothermic circulatory arrest combined with antegrade cerebral perfusion using a heart-lung machine, which we also use in thoracic or thoracoabdominal aneurysms. Close post-operative follow-up in a Marfan centre is pivotal for the early detection of pathological changes on the diseased aorta.

Objective. To assess the quality of life and satisfaction with postoperative outcomes in patients with breast cancer after immediate two-stage breast reconstruction. Material and methods. We analyzed aesthetic results and satisfaction with postoperative outcomes in 176 women aged 23-63 years (mean 42.9±8.1) with various stages of breast cancer. All patients underwent total mastectomy and immediate two-stage breast reconstruction with tissue expander/implant. Results. According to the Assessment of Cosmetic Results after Organ-Preserving Operations, Oncoplastic Resections, Reconstructive Plastic Surgery in Patients with Breast Cancer questionnaire, mastectomy with immediate two-stage breast reconstruction was followed by excellent results in 21.9% (16/73) of cases, good results — 64.4% (47/73), satisfactory results — 13.7% (10/73). According to the BREAST-Q questionnaire, all women were satisfied with post-reconstruction outcomes: reconstructed mammary gland — 64 scores, postoperative result — 70 scores, psychosocial well-being — 68 scores, sexual well-being — 64 scores, physical well-being — 80 scores. Conclusion. Immediate two-stage breast reconstruction has a beneficial effect on psycho-emotional state of women. A two-stage breast reconstruction technique with tissue expanders and implants usually provides good and excellent cosmetic results.

VAGINAL CONSTRUCTION IN CHILDREN

Human facial nerve regeneration was compared in three repair systems: autologous neural cable grafts (N = 56), direct end-to-end anastomosis (N = 34), and VII–XII anastomosis (N = 26). The data were analyzed based on the following criteria: facial symmetry and muscle tone at rest, degree of total facial reinnervation, voluntary motion, synkinesis, and electrophysiological testing. Facial tone and symmetry at rest and electrophysiologic tests were similar, while voluntary motion and facial reinnervation were decreased and synkinesis increased in the autologous cable graft repairs and VII–XII anastomosis. Electrophysiologic tests of the innervated muscles failed to distinguish between the three repair methods in successful regenerates. Neural cable grafts and VII–XII anastomosis were associated with more mass movement less fine precise emotive facial movement and more synkinesis. Excellent results, especially cable graft repairs, diminish with time because of continual progressive synkinesis, which may take up to 4 years to develop.

A 6-year-old female with no past medical history of remark, presents to our dermatology clinic with a history of acute left strabismus secondary to trauma 6 months prior to consultation. She was initially evaluated by ophthalmology and diagnosed with Brown's syndrome (BS), for which intradermal injection of 40 mg of triamcinolone in the left interciliary region was indicated, with full recovery of strabismus. Seven weeks following the procedure she presented with a rapidly progressive frontal atrophic plaque, for which she was referred to dermatology. At physical examination, a V-shaped atrophic plaque was observed extending from the left inner ciliary region up to the ipsilateral frontal hairline, with no signs of inflammation (Figure 1a,b). An initial diagnosis of localized linear scleroderma (morphea “en coupe de sabre”) was suspected for which studies were performed: brain MRI and CT and serologic test results were normal. The skin ultrasound was consistent with local subcutaneous atrophy and no inflammatory findings were informed, so a 4 mm-punch skin biopsy was performed. Histopathology revealed atrophy of the subcutaneous tissue with small adipocytes and numerous capillaries. There were no signs of inflammation, dermal fibrosis, or adnexal atrophy (Figure 2a,b). All prior findings were compatible with lipoatrophy secondary to steroid infiltration. Watchful waiting was suggested, the atrophic plaque showed progressive improvement with excellent clinical results at 18 month follow-up (Figure 1c,d). BS is characterized by restriction of the superior oblique tendon-trochlear complex and may be acquired by inflammation, trauma or surgery.1-3 Intra-trochlear triamcinolone is a well-known procedure to treat BS secondary to trochleitis.4 This procedure allows directing a high concentration of the drug directly to the site of the lesion, with promising results. Cases of linear cutaneous hypopigmentation and atrophy secondary to intralesional steroid injection have been reported in the literature.5-10 The depth and concentration of the steroid injection determines the site of atrophy. Regarding pathogenesis, it is believed that insoluble steroid crystals move along lymphatic vessels and cause localized lipolysis and skin depigmentation along the perilymphatic skin.5 In our case, from physical examination linear morphea was considered initially as a differential, but the absence of previous inflammatory signs, the acute onset of skin atrophy following steroid injection, the localization of the atrophic plaque in accurate accordance with the injection site and histopathology led us to the diagnosis of lipoatrophy secondary to intralesional steroid injection. Reports in the literature have shown spontaneous resolution within 6–12 months of corticosteroid injection, therefore watch full was initially recommended.6-10 If atrophy persists more than 1 year, fat or hyaluronic acid filler may be considered.5 In our case, at 18 month follow-up the atrophic plaque was almost imperceptible. It is important to recognize this infrequent complication secondary to intralesional steroid injection in order to avoid potential misdiagnosis and possible indication of systemic therapy. We also believe this case represents the first reported case of linear frontal atrophy secondary to intralesional steroids in a child. No funding sources supported the work. No conflict of interest disclosures. The patient's parents/guardians in this manuscript have given written informed consent to the publication of their case details. Data sharing is not applicable as no new data was generated.

1. GABAergic mechanisms in the midbrain periaqueductal gray (PAG) have been proposed to control the activity of descending antinociceptive systems and defensive behavior. Here, the effect of neuronal disinhibition by gamma-aminobutyric acid (GABAA) receptor blockade at midbrain sites on spinal neuronal responses to noxious and innocuous skin stimulation was quantitatively characterized. It was compared with the effect of direct neuronal excitation by glutamate microinjections or electrical stimulation at identical sites. Changes in mean arterial blood pressure and other nonsomatosensory responses were also assessed. 2. Responses of 101 multireceptive lumbar spinal dorsal horn neurons to noxious radiant skin heating (50 degrees C, 10 s), innocuous skin brushing, and electrical stimulation of primary afferent A- and C-fibers were recorded in deeply pentobarbital-anesthetized rats. The mean blood pressure was continuously monitored in one carotid artery, and other nonsomatosensory parameters, such as frequency and depth of spontaneous respiration and contractions of abdominal and facial muscles, were classified according to their relative intensity into five groups. 3. A fine, multibarrel glass pipette was constructed for monopolar electrical stimulation and microinjection of the GABAA receptor antagonist bicuculline (40, 200, or 400 pmol), or glutamate (10-50 nmol), or Fast Green dye in 50 or 100 nl at identical sites in the midbrain. 4. Bicuculline microinjections into discrete regions of the PAG selectively abolished spinal neuronal responses to noxious skin stimulation but did not affect brush-evoked responses or responses to electrical A-fiber stimuli. This antinociception was often, albeit not necessarily, accompanied by tachypnoea and abdominal and facial muscle contractions and changes--mostly increases--in mean arterial blood pressure. Injections into other areas of the PAG and adjoining ventral tegmentum (VT) were less effective. The vast majority of injection sites in the lateral tegmentum (LT) were ineffective. 5. Glutamate microinjections at midbrain sites to detect areas of origin of descending antinociceptive neurons were characterized by a high incidence (greater than 50%) of false-negative results, as bicuculline was shown to be effective at numerous glutamate-insensitive sites. Glutamate microinjections into some sites of the PAG and adjoining VT reduced, but did not abolish, spinal neuronal responses to noxious skin heating. Injections into the LT were ineffective. 6. The efficacy of electrical stimulation at midbrain sites on spinal nociceptive responses had no predictive value for the effect of glutamate or bicuculline.(ABSTRACT TRUNCATED AT 400 WORDS)