| boTulInum ToxIn A | arTICle
by palpation and topographical landmarks(12,16,18,23-27). Patients who possess thinner, less sebaceous skin with
finer wrinkles and shallower skin furrows and folds that can be spread apart and reduced with the fingers (‘glabellar spread test’) seem to have better, longer-lasting results(13). There are, however, some patients who are more difficult to treat because they are less responsive to the effects of onabotulinumtoxinA. In this group of more difficult to treat patients, there is one type of patient who possesses thick sebaceous skin with deep, intractable wrinkles whose furrows are difficult to pull apart with the fingers. usually these turn out to be men and sometimes women who spend a lot of time outdoors. The other type are those who possess the inelastic, redundant skin seen with dermatochalasis and whose furrows are also deep but very easy to pull apart. These patients characteristically are older and unfortunately are not ideal candidates for glabellar chemodenervation, because frequently their final outcomes are less than ideal. Typically, in these patients, after having onabotulinumtoxinA injected with impeccable technique, the resultant relaxation of the glabellar muscles causes in folding of the lax and redundant glabellar skin. Consequently, there remains some evidence of frown lines and wrinkles even if higher doses of onabotulinumtoxinA are subsequently injected. Generally, glabellar frown lines in women can be
satisfactorily treated with a total dose of about 20–30 u or more of onabotulinumtoxinA injected into the standard five injection sites (Figure 4)(4,11,23,33–39). men, on the other hand, usually require a significantly higher dose of onabotulinumtoxinA (40–80 u) injected at seven sites
Generally, glabellar
frown lines in women can be satisfactorily treated with a
across the glabella and medial brow to produce a reasonable effect that lasts at least 3–4 months(3,27,28-30) (Figure 5). When glabellar lines are deeper, longer, or thicker on one side of the midline that set of medial depressors muscles (e.g. corrugator supercilii, depressor supercilii and medial aspect of the orbital orbicularis oculi) should receive a slightly higher dose of onabotulinumtoxinA than the medial depressors on the contralateral side. The two injection points in addition to the standard five are those given over the midpupillary line, bilaterally, which usually are needed when treating men, so that the midbrow does not elevate and become more arched than is generally the case naturally(31). Remember to remain at least 1–2 cm above the orbital rim at the midpupillary line to avoid blepharoptosis.
total dose of about 20–30 u or more of onabotulinumtoxina injected into the standard five injection sites.
Frontalis Some injectors have felt that the glabella should be treated separately and in one session first, before the frontalis is treated, which should be done in a subsequent session, especially with first time patients(3,28). They feel that some of the
Figure 4 A 3/10 ml Becton- Dickinson insulin U-100 syringe with a 31-gauge needle swaged directly onto the syringe. Note the absence of any dead space between the hub of the needle and the neck of the syringe. Each unit notch on the barrel corresponds to 0.01 ml or 1 U
frontalis will be influenced by the diffusion of onabotulinumtoxinA when the glabella is treated first *A. This consequently can reduce the amount of wrinkling remaining on the forehead which in turn lowers dosage requirements and which may change the injection pattern required to treat the frontalis. ultimately this may produce a better final result. Recently, however opinions have reversed and more and more injectors currently are treating the forehead and the glabella during the same session, and results seem to be comparable and just as effective(28,32).
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