arTICle | boTulInum ToxIn A |
5-point injection technique is corrective with 4 – 10 u of onabotulinum-toxinA given at each injection point (Figure 9c) (15). Stronger, more hyperkinectic corrugators and procerus produce similar glabellar frown lines but they are deeper and more acute, resulting in a pattern that better resembles a “V”. This was seen in 37% of the patients studied (Figures 10a & b). Higher doses of onabotulinumtoxinA in the 7-point injection pattern is usually necessary to diminish these lines(15). (Figures 10a, b, c & d)
fibers of the procerus are injected with at least 4 u of
onabotulinumtoxinA, while the stronger ones usually can be injected with up to 10 u and possibly even more in one, two, or more injection points. The depressor supercilii already will have been partially treated by the injections given at the medial aspect of the superciliary arch and eyebrows when the medial orbital orbicularis oculi is treated. likewise, when the procerus is injected some diffusion of the onabotulinumtoxinA into the interdigitating fibers of the depressor supercilii and medial orbital orbicularis oculi will occur, particularly when gentle massage upward and laterally is performed to the right and left immediately after injection. Some patterns of glabellar frowning are seen more
frequently than others(15). The most common pattern forms observed by Trindade de Almeida were those produced by the simultaneous adduction and depression of the glabella (64%). This occurs when the corrugators contract and parallel vertical lines are formed in the center of the glabella as the skin of the brow moves toward the midline. At the same time, the procerus pulls the skin of the brow inferiorly, forming horizontal lines at the root of the nose. There are two distinct patterns when this happens. The less frequently observed pattern (27%) is what Trindade de Almeida calls the “u” pattern(15) (Figures 9a & b). In these patients, the
Figure 11 (A) More depression than adduction of the medial brow with this “inverted omega” pattern of glabellar frowning. Note the deep horizontal line at the root of the nose. (B) Less frequently seen type of glabellar adduction producing an “inverted omega” pattern of frown lines. Muscles involved: mostly the procerus and depressor supercilii. (C) A different seven point pattern of injection for this uncommon glabellar “inverted omega” pattern. Higher doses of onabotulinum-toxinA are needed
for the procerus. Source: Courtesy of Trindade de Almeida. (D) Same patient frowning 2 weeks after onabotulinumtoxinA treatment
Outcomes (results) When proper injection techniques are followed, results are predictable and reproducible. The vertical lines between the eyebrows and the horizontal rhytides across the root of the nose will diminish and usually disappear. Glabellar and mid brow corrugations if treated appropriately also will be reduced and temporarily eliminated. There can be a noticeably high arching of the eyebrows
of approximately 2–3 mm, caused by the levator action of the frontalis in those patients whose glabellar depressors have been substantially weakened, but the interdigitating muscle fibers of the frontalis immediately above the brow have not(35-37) (Figure 11). There also can be an increase in the distance between the eyebrows and an elevation of the medial aspect of the eyebrows when glabellar frown lines are treated with onabotulinum- toxinA because of the dynamic relationship between the brow depressors (corrugator, orbicularis oculi, procerus, depressor supercilii) and their brow levator (frontalis) (26,35-37). Accentuated high arching eyebrows may be attractive in most women, but usually are not in men. In order to avoid a high arching brow in men, an additional 4–6 u of onabotulinumtoxinA can be injected intradermally 1.5 – 2.0 cm above the supraorbital margin at the midpupillary line (Figures 12a, b, c & d) (6,38). usually, one can expect the effect of an
Glabellar and mid brow
corrugations if treated appropriately will be
reduced and temporarily eliminated.
onabotulinumtoxinA treatment of glabellar frown lines to last at least 3–4 months. Patients who are treated for the very first time with onabotulinumtoxinA may experience some asymmetry and therefore should return for an evaluation and possible touch-up injections within 2–3 weeks after a treatment. Frequently, the effects of onabotulinumtoxinA may last longer with each
Treatment-implications to consider when injecting the glabella 1 Accurate amounts of precisely
placed injections of minimal
volume onabotulinumtoxinA reduce the incidence of brow and eyelid ptosis.
2Men may need higher doses of for comparable results.
eyebrows. 44 ❚
onabotulinumtoxinA, remain medial to the midpupillary line and 1.5–2.0 cm above the supraorbital bony margin, and deep within the belly of the muscle.
onabotulinumtoxinA than women 5Blepharoptosis can be transiently 3Women prefer arched eyebrows;
reversed with alpha-adrenergic
men prefer straight, non-arched 4When injecting the corrugator
supercilii with March 2011 |
prime-journal.com
agonist eye drops, but brow ptosis cannot be reduced and remits only when the effects of onabotulinumtoxinA diminish.
brow and eyelids should be identified and discussed with the
6Pre-existing asymmetry of the
patient before treatment, and might be corrected by accurately injecting appropriate doses of onabotulinumtoxinA on both the affected and non-affected side.
compensatory brow lifting because of a pre-existing blepharoptosis can easily develop pseudoblepharoptosis when injections of onabotulinumtoxinA decompensate their brow lifting on the affected side.
7Patients with inelastic, redundant skin of the brow who have
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