CC
A 44-year-old female presents to your office for consultation regarding the wrinkles and overexpression on her forehead. Patients with dynamic wrinkles, which are formed during facial expressions, have the best indication for botulinum toxin (BoTN) injections. Static wrinkles can also be treated by BoTN. However, the results are less dramatic, and adjunctive treatments such as fillers may be needed.
PMHX/PDHX/medications/allergies/SH/FH
The patient does not have any known medical conditions. Specifically, she has no known history of neuromuscular disorders, including myasthenia gravis or Lambert–Eaton syndrome or neurodegenerative diseases such as amyotrophic lateral sclerosis. (Despite the absence of specific studies, BoTN should be used cautiously in individuals with neuromuscular disorders because of the potential exacerbation of any preexisting conditions.) There is no significant family history of neuromuscular disorders.
The patient is not currently taking any aminoglycoside antibiotics or other medications that could interfere with neuromuscular transmission. (It is recommended that BoTN injections be delayed or avoided in patients taking aminoglycosides.) She is not taking aspirin, a nonsteroidal antiinflammatory drug, or other medication that can interfere with coagulation or platelet function (such drugs increase the risk of hematoma formation and bruising). She smokes a half pack of cigarettes per day. (Smoking is not a contraindication to BoTN injection.)
There is no history of allergies to human albumin or of any previous adverse reactions to BoTN. (Human albumin [HSA] is added to most commercially available BoTNs. It is thought that HSA stabilizes and protects BoTN from unspecific binding to glass and plastic surfaces.)
The patient is not pregnant or lactating at this time. (BoTN is contraindicated during nursing or pregnancy; it is classified by the US Food and Drug Administration [FDA] as Pregnancy Category C, meaning that its safety profile during pregnancy has not been studied. It is unknown whether the toxin can cross the placenta or is excreted during lactation. However, the localized application of the drug would suggest the safety of application during pregnancy or nursing).
Examination
General. The patient is a thin, well-dressed female. She wears an extensive amount of makeup, which masks some of her age-related facial features. She wears her hair in a style that reduces the visibility of the forehead lines. (Subtle observations about appearance may be the key to successful patient rapport.)
Maxillofacial. There are no pustules or signs of active dermatologic infections or pathology in the facial region. (Injections are contraindicated if an active infection exists at the injection site.) There is no marked facial asymmetry or hypertrophic scarring. (Thick skin or a susceptibility to hypertrophic scars may be a relative contraindication to injections.) No significant eyebrow ptosis is noted. (This is important for injections around the eyes or on the forehead. Impairing the functioning of the frontalis can also lower the eyebrow position from unopposed muscle action, resulting in an unappealing outcome. Similarly, large amounts of BoTN injected around the eye can diffuse toward the levator palpebrae muscle, causing impaired eyelid closure. The degree of preoperative ptosis can be documented for postoperative comparison.)
Several prominent horizontal forehead wrinkles (caused by frontalis muscle action) are present at rest ( Fig. 82.1 A) and are accentuated with animation ( Fig. 82.1 B). Multiple hyperdynamic rhytids (lines on the face) are seen lateral to the eye and are most pronounced on animation (orbicularis oculi region, also known as “crow’s feet”; Fig. 82.2 ). At rest, fine vertical glabellar furrows are present, and upon animation and frowning, the glabella muscle bulge becomes significantly more prominent ( Fig. 82.3 ). (The corrugator muscle is responsible for the vertical glabellar furrows, and the procerus muscle is responsible for the horizontal glabellar furrows.) A glabellar spread test reveals that the glabellar lines are substantially reduced when physically manipulated or spread apart. (This is a good indication that the muscle and its overlying soft tissue are the etiology of the lines. During the physical examination, it is important to distinguish between dynamic and static wrinkles.)
No significant horizontal lines are present at the nasal root (“bunny lines”), and no prominent perioral vertical (“lipstick”) rhytides are visible.
Imaging
Standard facial photographic documentation of the areas to be treated is recommended for BoTN injection. Comparisons of preinjection and postinjection photograms may be important for future dosing and for surgeon education toward optimal results.
Labs
No routine laboratory tests are indicated in healthy patients.
Assessment
Multiple areas of hyperfunctioning facial muscles and signs of aging are present involving the periorbital, glabellar, and horizontal forehead regions. The patient desires injection of BoTN for effacement of the wrinkles associated with the periorbital and forehead regions. (Although there may be many findings amenable to cosmetic surgery, the assessment and treatment are dictated by the patient’s desires.)
Treatment
After a complete discussion of the procedure, risks, and alternatives, the patient signed the informed consent (which addressed all the complications listed later). Botox was chosen for the treatment of this patient. (There are five BoTN products that have FDA approval for cosmetic use: Dysport, Botox, Xeomin, and Daxi.). A vial of 100 units of BoTN A was reconstituted with 3.3 mL of nonpreservative normal saline. (Many practitioners use preservative saline because they believe it causes less pain during injections; see Discussion.) Botox is available in a sealed vacuum container that allows for easy reconstitution with saline. The resulting solution provides 3 units per 0.1 mL or 15 units per 0.5 mL. Botox should be reconstituted by gentle side-to-side movements or rolling the vial. (Shaking and trauma to the toxin can diminish its potency.)
The patient was seated upright, close to a 60-degree position. After the injection sites had been prepared with alcohol, the patient was asked to frown (or lower the eyebrows) to highlight the regions of maximum muscular contraction. Twelve injection sites were identified to inject the frontalis muscle ( Fig. 82.4 ). To minimize the chance for blepharoptosis, the injections were performed at least 1 cm above both the central eyebrow and the supraorbital ridge. It is important to avoid injections on the forehead lateral to the lateral canthus to prevent inhibition of temporalis function. The goal of forehead injections is not to completely eliminate the frontalis muscle action because this can cause undesirable eyebrow ptosis. Ice packs were applied immediately before the injection to blunt the pain response from the needle. The needle was inserted into the belly of the muscle, aspiration was performed, and Botox was then slowly injected. After the injections, no manipulation was performed, and an ice pack was allowed to rest on the area. (Manipulation can enhance diffusion into other muscles, affecting the levator palpebrae superioris and causing blepharoptosis, especially with injections near the eyelid.) Attention was then turned to the orbicularis oculi region. After the area had been prepared with alcohol, 9 units total were injected into three sites on each side just below the skin (to minimize diffusion in this area). A total of 36 units were used for the forehead and crow’s feet regions (18 units in the forehead and 18 units total for both eyes) (see Fig. 82.4 ).
