| boTulInum ToxIn A | arTICle
Figure 9 (A) Mild to moderate approximation and depression of the medial brow forming typical and most
commonly seen glabellar frown lines (the “U” pattern). (B) Commonly seen “U” type of glabellar contraction and resulting pattern of frown lines. Muscles involved: predominantly the corrugators and procerus. (C) Five point pattern of injection for this most commonly encountered
glabellar “U” pattern. Source: Courtesy of Trindade de Almeida.
(Figure 7a). These corrugations can be reduced by injecting 4 – 10 u of onabotulinumtoxinA deeply into the belly of the corrugator supercilii (i.e. at the medial aspect of the eyebrow) and 4 – 10 u intradermally near where the corrugators insert into the mid brow, which is just medial to the supraorbital notch or mid pupillary line (Figures 7b & c). The medial brow injections are given deeply directly into the belly of the corrugator, while the more lateral injections over the mid brow should be applied superficially since the fibers of the corrugators in this location are superficial and insert into the under surface of the skin. These injections should reduce the adduction of the brow and eliminate corrugations.
Procerus next, an injection of approximately 4–10 u of onabotulinumtoxinA is given between the eyebrows at the nasal root into the belly of the procerus and into the interdigitating fibers of the depressor supercilii and medial fibers of the orbital orbicularis oculi (Figure 8). The dose needed for this injection of onabotulinumtoxinA
Those that are more resistant to treatment with
onabotulinumtoxina commonly
are found in men and women who spend a lot of time outdoors.
Figure 10 (A) Moderate to severe approximation and depression of the medial brow forming very deep glabellar frown lines (the “V” pattern) in this 62-year-old woman. (B) Vigorous glabellar contraction and resulting “V” pattern of frown lines. Muscles involved: strong corrugators, procerus, and medial aspect of the orbicularis oculi. (C) Seven point pattern of injection for this exaggerated glabellar “V” pattern. Higher doses of onabotulinumtoxinA usually are needed for treatment. Source: Courtesy of Trindade de Almeida. (D) Same patient frowning and at rest two weeks after an onabotulinumtoxinA treatment.
will depend upon the overall muscle strength and depth of the horizontal glabellar wrinkles that are present(18). The strength of the procerus can be determined by gently palpating the glabellar area with the pads of the second and third fingertips of the non-dominant hand while the patient repeatedly squints and frowns.
Glabellar wrinkles tend to be deeply fixed in the skin, especially the horizontal ones. Those that are more resistant to treatment with onabotulinumtoxinA commonly are found in men and women who spend a lot of time outdoors, because their glabellar muscles are significantly hypertrophied from frequent squinting. Intramuscular instead of subcutaneous injections of onabotulinumtoxinA into the procerus can be accomplished by gently grasping the soft tissue of the root of the nose between the thumb and the index finger of the non-dominant hand. Then elevate the skin and muscle before placing the needle between the two fingers and injecting onabotulinumtoxinA into one or two sites in the center of the nasal radix (Figure 8). The site of injection should be anywhere from 1–3 mm above or below the center of the nasion. The weaker muscle
prime-journal.com | March 2011
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