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    Cosmetic botulinum toxin appealing to patients, physicians

    Most patients pleased with results of injection for treating hyperkinetic facial rhytids

    Dr. Khan
    Kansas City, KS-Incorporating cosmetic botulinum toxin type A (Botox, Botox Cosmetic, Allergan) treatment into an ophthalmic practice's realm of services can be very satisfying for patients and the practitioner, said Jemshed A. Khan, MD.

    "Used carefully and in appropriate doses, botulinum toxin is highly safe and effective for treating facial rhytids," said Dr. Khan, clinical professor of ophthalmology, Kansas University School of Medicine, Kansas City, and in private practice, Overland Park, KS. "Patients like it because the treatment is so quick and results in no downtime. Up to 80% are pleased enough that they return long-term for repeat injections.

    "The minimal risks and revenue-generating opportunities are clearly appealing for physicians," he said. "But cosmetic botulinum toxin injection also offers a nice counterbalance for our more challenging cases, and the gratefulness of the patients treated can also be a source of professional satisfaction."

    When beginning to offer botulinum toxin injection for treatment of hyperkinetic facial rhytids, the best indications are for glabellar frown lines and in off-label use to minimize horizontal forehead creases and crow's-feet. Botulinum toxin injections can also be used to raise the temporal eyebrow, minimize vertical lip lines, and raise the outer corners of the lips, but those treatments are associated with higher rates of complications and are best avoided by physicians who are new to using botulinum toxin and in new patients, he said.

    "When treated around the mouth, patients can experience difficulty puckering and enunciating certain sounds and may have problems with drooling," Dr. Khan said. "Overall, perhaps only about 50% of these patients are happy with the results, and so that is not a good indication for a first use of botulinum toxin in a new patient."

    He also cautioned that botulinum toxin cannot be used to minimize the nasolabial folds, and, in fact, can worsen their appearance. For that reason, it is also important when treating crow's-feet to avoid injecting too far inferiorly over the malar projection into the zygomaticus major and minor muscles, because that will result in a droopy appearance of the mid-face.

    Figure 1 Patient before botulinum toxin type A injection to forehead rhytids.
    Dosing and techniqueTo treat glabellar frown lines, botulinum toxin is delivered into the procerus muscle and the two corrugator muscles. For initial treatment, the total dose is usually 25 units, with 5 units injected into the midline procerus and two 5-unit injections administered into each corrugator muscle.

    "Men often need a slightly higher dose than women, probably reflecting presence of greater muscle mass, but even with a higher dose, the duration of response is usually shorter in men than in women," Dr. Khan said.

    The injection should not be delivered into the supraorbital neurovascular bundle, so the physician should palpate for the supraorbital notch. Although the notch may not be felt in all people, the neurovascular bundle is generally located about 1 inch lateral to the midline, and so the two injections can either be given medially to that point or one laterally and one medially, he explained.

    In treating forehead lines, the total dose and number of injection sites is more variable due to differences in forehead length. As a rule of thumb, the physician can determine the number of injections needed by estimating each will treat an area 3 to 4 cm in diameter. The average patient might require four injections, each delivering 2 to 4 units of toxin.

    Dr. Khan cautioned physicians to be conservative with the dose initially and be certain to deliver the injections in the upper third of the forehead, because treatment too far inferiorly can lead to inability to raise the brows as well as brow ptosis.

    "If you overtreat the forehead the first time, patients will be dissatisfied with the dropped eyebrow-forehead complex look and will not come back," he said.

    It is also important to try to inspect for visible subsurface vessels so they can be avoided and to assess how far laterally the frontalis extends so that the most lateral aspect is treated. Otherwise, patients will exhibit a "devilish" look when trying to raise the brows because only the temporal brow is elevated.

    "Ask the patient to lift the brows and palpate for the frontalis muscle, but if you don't inject far enough laterally, you can always go back later and add an extra 3 units," Dr. Khan said.

    Minimizing the appearance of crow's-feet usually requires three injections on each side of the face with 3 to 4 units per injection site. At this region, each injection will immobilize the muscle in an area about 1.5 to 2 cm in diameter, and the exact administration sites can be individualized by asking patients to reproduce the wrinkles by squinting.

    "There is some interpatient variability in where the wrinkles appear when the orbicularis oculi muscle is tightened," Dr. Khan said. "Age is one factor, because younger people tend to have more minor wrinkles at the lateral orbital rim and may require only a single injection of 5 units, while older people may have longer radiating lines covering a larger area and may be more likely to need three or even four injections over the lateral orbital rim or even further laterally."

    When injecting in the crow's-feet area, the physician also should look carefully for subsurface vessels and avoid injecting directly into them, he advised. In addition, Dr. Khan noted he delivers the toxin subcutaneously at this site versus into the muscle to minimize bleeding.

    Other treatment tipsThere are different protocols for reconstituting botulinum toxin type A, but Dr. Khan recommended adding 2.2 ml of preserved saline to each vial. Because not all of the solution can be withdrawn from the bottle, dosing determinations should be based on a final concentration of 100 units per 2.0 ml.

    Figure 2 Patient after treatment. Note the relaxation of forehead creases. (Photos courtesy of Jemshed A. Khan, MD)
    Although the labeling directions state preservative-free saline should be used, use of preserved saline will increase the stability of solution stored in the refrigerator. Once the diluent is added, the vial should be gently rolled between the hands and not agitated because that will inactivate the toxin.

    Dr. Khan performs his injections using an insulin syringe with a pre-attached 30-gauge needle, noting that there will be loss of some toxin in the needle hub if a syringe is fitted instead with a detachable needle. He also cautioned users to be careful not to dull the needle as they insert it into the vial to withdraw the toxin.

    Pre-injection application of ice packs and wiping the area with an alcohol wipe just prior to injection are helpful strategies for reducing patient discomfort. Engaging the patient in conversation during the injection as a distraction technique is helpful as well, Dr. Khan suggested.

    "We also offer an anesthetic ointment to be applied 10 to 20 minutes prior to the injection, but few patients actually use that," he said.

    After injection, patients are instructed to apply pressure to the injection sites with a facial tissue to stop any bleeding. Dr. Khan also recommended assessing efficacy by having patients return about 6 weeks after the initial treatment.

    "The toxin should be working well at that time and you will be able to determine if any dosage adjustment is needed," he concluded. "However, if the patient does not come back for 3 months, the treatment effect may already be wearing off and it will be harder to judge whether any modifications are needed for repeat treatment."

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