articLe | BOTulInumTOxIn A |


CosmetiC uses of botulinum toxin A in the mid fACe


Anthony V. Benedetto explains functional anatomy, dosing, outcomes, and complications when treating the mid face with onabotulinumtoxina


with their treatments (1). at this time, all of these treatments (in the United states) are not approved by the food and drug administration (fda), and are performed in an off-label manner. One must be completely knowledgeable of the levator


W


ANTHONY V. BENEDETTO, DO, FACP is a Clinical Associate Professor of Dermatology at the Department of Dermatology, University of Pennsylvania School of Medicine. Dr Benedetto is the founder and medical director of the Dermatologic SurgiCenter in Philadelphia, PA and in Drexel Hill, PA, where he practices Mohs Surgery and Cosmetic and Procedural Dermatologic Surgery


email avb@benedettoderm.com


KEYWORDS Botox, injection, nasoglabellar, bunny line, gummy smile, wrinkles, nasolabial


18 ❚ May 2011 | prime-journal.com


and depressor action of the mimetic musculature. The reciprocating action of opposing mimetic muscles can be slightly more complicated and challenging in the mid and lower face than in the upper face.


Upper face versus mid face There are a number of factors that contribute to the differences in the anatomy of the upper face as compared to that of the mid and lower face, which will reflect how one is to inject onabotulinumtoxinA when rejuvenating the face (2). In the upper face, the skin can be thicker and more


tightly adherent to the underlying muscles of facial expression. Generally, much higher doses of onabotulinumtoxinA are injected into the upper face musculature, but onabotulinumtoxinA treatments here rarely cause functional imbalance. However, owing to their compact spatial arrangement and indistinct borders,


ith increased demand for facial


rejuvenation via


noninvasive techniques, many experienced injectors of onabotulinumtoxina now are venturing below the upper face


the mid and lower facial musculature should be treated with lower doses of onabotulinumtoxinA to gently weaken activity and prevent diffusion. Wrinkles in the mid and lower face tend to be more static in nature as compared to those in the upper face, which are more dynamic in origin (3,4). Particularly in the mid face, wrinkles develop and are enhanced because of photodamage, volume loss, and soft tissue shifting (5). This is one of the reasons why deep longstanding wrinkles and furrows in the mid and lower face cannot always be totally effaced with onabotulinumtoxinA. Persistent treatments with escalating doses can result in anatomic aberrations and functional imbalance without satisfactorily diminishing the unwanted wrinkles. In order to maintain the functional as well as an


anatomic balance in the mid and lower face when treating a patient with injections of onabotulinumtoxinA, it is absolutely necessary, more so than in the upper face, that accurately measured, minimal volumes of low doses be precisely placed and injected into specifically targeted muscles. The upper lip levators are easily affected by the slightest diffusion of onabotulinumtoxinA. This can readily cause a disruption in one or many of the complex motor functions of the lips. Also, because of the intermingling of the orbicularis oris with the muscle fibres of the upper lip levators, which are invested with a thicker mass of subcutaneous soft tissue, onabotulinumtoxinA injections of the mid face should be performed by an expert injector (6).


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84