Balanced Botox Chemodenervation of the Upper Face: Symmetry in Motion

ABSTRACT

Cosmetic botulinum toxin type A (Botox, Allergan, Inc., Irvine, CA) has revolutionized minimally invasive treatment of the upper face. Increasingly sophisticated outcomes result in facial symmetry in motion. The face is a three-dimensional moving unit, not an isolated photograph. This is why the advanced injector must hone an astute ability to observe casual microexpressions. Consideration is then given to the patient's age, facial anatomy, facial asymmetry, and dynamic rhytids. The ratio of dosing to agonist and antagonist muscles that allows unopposed action is determined. Nuance in placement and dose combined with adjunct therapy results in natural and appropriate facial emotion and avoids unnatural or bizarre patterns of movement. Asymmetrical scenarios are presented to exemplify this process of analysis and treatment. Many authors have detailed the mechanism of action, history of Botox development, and specific muscle group treatment in the periorbital region. In this discussion, I leave behind rigorous academic analysis and wish to offer my approach, which has evolved through 15 years experience treating the aesthetic patient with Botox. The clinician can read about recommended patterns of injection, and the procedure is quite simple. It is only through skilled observation and understanding of expressive nuance and anatomy that the advanced injector will meet the goal of a natural communicative result with chemodenervation. Experience is accumulated through critical analysis of patient results over time. This discussion first directs attention to why it is important to learn how to look at the face in motion as well as at facial rhytids. A plan is developed for treatment including drug preparation, dosing decisions, precise three-dimensional delivery, and adjunct therapy. Perils may generally be avoided by choosing appropriate dosing and placement. The asymmetrical patient scenario is used to demonstrate nuance in evaluation and treatment.

Botox - chemodenervation - symmetry - motion

REFERENCES

• 1 Carruthers A, Carruthers J. Botulinum treatment of forehead wrinkles.  Plast Reconstr Surg. 2006;  117 1354
• 2 Carruthers A, Carruthers J. Botulinum toxin type A for the treatment of glabellar rhytides.  Dermatol Clin. 2004;  22 137-144
• 3 Carruthers A. Botulinum toxin type A: history and current cosmetic use in the upper face.  Dis Mon. 2002;  48 299-322
• 4 Carruthers J, Carruthers A. Botulinum toxin below the eyes.  Int Ophthalmol Clin. 2005;  45 133-141
• 5 Carruthers J, Fagien S, Matarasso S L. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics.  Plast Reconstr Surg. 2004;  114(6 suppl) 1S-22S
• 6 Carruthers J, Carruthers A. Botox: beyond wrinkles.  Clin Dermatol. 2004;  22 89-93
• 7 Carruthers J, Carruthers A. Botulinum toxin (botox) chemodenervation for facial rejuvenation.  Facial Plast Surg Clin North Am. 2001;  9 197-204
• 8 Fagien S. Botulinum toxin type A for facial aesthetic enhancement: role in facial shaping.  Plast Reconstr Surg. 2003;  112(suppl) 6S-18S
• 9 Fagien S, Brandt F S. Primary and adjunctive use of botulinum toxin type A (Botox) in facial aesthetic surgery: beyond the glabella.  Clin Plast Surg. 2001;  28 127-148
• 10 Ekman P. Facial expression and emotion.  Am Psychol. 1993;  48 384-392
• 11 Ekman P. Darwin, deception, and facial expression.  Ann N Y Acad Sci. 2003;  1000 205-221
• 12 Ekman P, Friesen W V, O'Sullivan M. Smiles when lying.  J Pers Soc Psychol. 1988;  54 414-420
• 13 Ekman P. Asymmetry in facial expression.  Science. 1980;  209 833-834
• 14 Ekman P, Hager J C, Friesen W V. The symmetry of emotional and deliberate facial actions.  Psychophysiology. 1981;  18 101-106
• 15 Package insert Botox (botulinum toxin type A) Purified Neurotoxin complex. 2006 Ref Type: Generic
• 16 Kligman A M, Zheng P, Lavker R M. The anatomy and pathogenesis of wrinkles.  Br J Dermatol. 1985;  113 37-42
• 17 Flynn T C, Carruthers J A, Carruthers J A. Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye.  Dermatol Surg. 2001;  27 703-708
• 18 Alam M, Dover J S, Arndt K A. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind, randomized controlled trial.  Arch Dermatol. 2002;  138 510-514
• 19 Flynn T C, Carruthers A, Carruthers J. Surgical pearl: the use of the Ultra-Fine II short needle 0.3-cc insulin syringe for botulinum toxin injections.  J Am Acad Dermatol. 2002;  46 931-933
• 20 Knize D M. Muscles that act on glabellar skin: a closer look.  Plast Reconstr Surg. 2000;  105 350-361
• 21 Knize D M. An anatomically based study of the mechanism of eyebrow ptosis.  Plast Reconstr Surg. 1996;  97 1321-1333
• 22 Putterman A M. Botulinum toxin injections in the treatment of seventh nerve misdirection.  Am J Ophthalmol. 1990;  110 205-206
• 23 Balikian R V, Zimbler M S. Primary and adjunctive uses of botulinum toxin type A in the periorbital region.  Facial Plast Surg Clin North Am. 2005;  13 583-590
• 24 Fagien S. Temporary management of upper lid ptosis, lid malposition, and eyelid fissure asymmetry with botulinum toxin type A.  Plast Reconstr Surg. 2004;  114 1892-1902
• 25 Kane M A. Classification of crow's feet patterns among caucasian women: the key to individualizing treatment.  Plast Reconstr Surg. 2003;  112(5 suppl) 33S-39S
• 26 Paloma V, Samper A. A complication with the aesthetic use of Botox: herniation of the orbital fat.  Plast Reconstr Surg. 2001;  107 1315
• 27 Aristodemou P, Watt L, Baldwin C, Hugkulstone C. Diplopia associated with the cosmetic use of botulinum toxin a for facial rejuvenation.  Ophthal Plast Reconstr Surg. 2006;  22 134-136
• 28 Wutthiphan S, Kowal L, O'Day J, Jones S, Price J. Diplopia following subcutaneous injections of botulinum A toxin for facial spasms.  J Pediatr Ophthalmol Strabismus. 1997;  34 229-234
• 29 Carruthers J, Carruthers A, Maberley D. Deep resting glabellar rhytides respond to BTX-A and Hylan B.  Dermatol Surg. 2003;  29 539-544
• 30 Carruthers J, Carruthers A. Adjunctive botulinum toxin type A: fillers and light-based therapies.  Int Ophthalmol Clin. 2005;  45 143-151
• 31 Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: adjunctive use in facial aesthetic surgery.  Plast Reconstr Surg. 1999;  103 701-713
• 32 Carruthers A, Langtry J A, Carruthers J, Robinson G. Improvement of tension-type headache when treating wrinkles with botulinum toxin A injections.  Headache. 1999;  39 662-665
• 33 Evers S, Rahmann A, Vollmer-Haase J, Husstedt I W. Treatment of headache with botulinum toxin A-a review according to evidence-based medicine criteria.  Cephalalgia. 2002;  22 699-710
• 34 Levenson R W, Ekman P, Heider K, Friesen W V. Emotion and autonomic nervous system activity in the Minangkabau of west Sumatra.  J Pers Soc Psychol. 1992;  62 972-988
• 35 Levenson R W, Carstensen L L, Friesen W V, Ekman P. Emotion, physiology, and expression in old age.  Psychol Aging. 1991;  6 28-35
• 36 Levenson R W, Ekman P, Friesen W V. Voluntary facial action generates emotion-specific autonomic nervous system activity.  Psychophysiology. 1990;  27 363-384
• 37 Ekman P, Levenson R W, Friesen W V. Autonomic nervous system activity distinguishes among emotions.  Science. 1983;  221 1208-1210