articLe | BOTulInumTOxIn A |
Proper patient selection is paramount, as untoward
sequelae resulting in a lack of control of essential buccal
sphincter functions can occur very easily and be devastating to the patient.
orbicularis oculi of the lower eyelid, can achieve an additive effect of diminishing lower lateral canthal rhytides along with effacing nasolabial folds (16). Depending on the idiosyncratic anatomy of an individual, shape of the face, and strength of muscles, it might be necessary to administer one, two, or multiple injections, each over the mid to lateral malar prominence, to obtain consistent results (5,16,22). This technique is always accompanied by a drop of the upper lip or a reduction in the lateral excursion of the oral commissures
pointed perpendicularly to the surface of the skin,
advance it approximately 3–5 mm deep and just before contacting bone so as not to inflict undue pain. Inject only 1 or 2 u directly into the thickest bulge of muscle contraction. Depending on position and depth of the nasolabial sulcus and the height of the nasolabial fold, the bulge of muscle contracture palpated may correspond to the interdigitating lower fibres of the levator labii superioris and zygomaticus minor, together with the lower lateral labial fibres of the levator labii superioris alaeque nasi. These injection techniques should be performed only
by the very experienced physician whose patient possesses nasolabial folds that are deep and become exaggerated with a simple upward movement of the upper lip. Proper patient selection is paramount, as untoward sequelae resulting in a lack of control of essential buccal sphincter functions can occur very easily and be devastating to the patient. The use of electromyographic guidance when treating this area can be helpful to the novice. For those who produce innumerable wrinkles of the
mid-cheek with smiling or squinting, an intradermal injection of 1–2 u of onabotulinumtoxinA near the origins of the zygomaticus complex along the inferior lateral margin of the zygomatic arch at the inferior border of the
Outcomes If one considers the levator labii superioris alaeque nasi, the principal muscle that creates the nasolabial fold, and the other central and lateral lip levators (the levator labii superioris, zygomaticus complex, levator anguli oris, and risorius) responsible for deepening the nasolabial sulcus when they contract, then precisely placed low-volume injections of onabotulinumtoxinA should be able to reduce the appearance of the nasolabial fold and the depth of its sulcus. As this is not the only or primary function of these muscles, injections of onabotulinumtoxinA can unwittingly produce secondary changes that interfere with and diminish the primary functions of these muscles, i.e. elevating the upper lip and laterally abducting the corners of the mouth. nasolabial fold effacement and its accompanying side-effects can last up to 3 months, or as long as the onabotulinumtoxinA treatment is effective. Petchngaovilai describes an intradermal injection
technique of highly diluted onabotulinumtoxinA, which relaxes what she considers the major depressors of the face (i.e. platysma and lateral orbicularis oculi) and allows the levators of the mid face (zygomaticus complex, levator labii superioris alaeque nasi, levator labii superioris, levator anguli oris) and lateral frontalis to reverse sagging and wrinkling of the upper and mid face (22).
Complications Just 1–3 u of onabotulinumtoxinA into each lip levator complex in the lower nasofacial sulcus will collapse the upper extent of the nasolabial fold and also elongate the upper lip, with fairly long-lasting results (1). However, injecting this area can result in a flat mid face with elongation of the upper lip, effacement of the philtrum,
Treatment implications when injecting the nose for a drop of the nasal tip 1When the depressor septi nasi
injections into the dilator naris toward the nasal tip may be necessary to elevate and project the tip of the nose.
26 ❚ May 2011 |
prime-journal.com 2In some patients, additional deep 4Over-treatment can
visibly depresses the tip of the nose when one smiles, speaks, puckers, or purses the lips, onabotulinumtoxinA injections will elevate and project the nasal tip.
3Injecting onabotulinumtoxinA
into the lateral aspect of the tip of the nose can cause an amplified widening of the nostrils.
cause excessive nostril widening, prolonged pain, an exaggerated elevation and a flattening of the nasal tip projection.
5Diffusion of onabotulinumtoxinA
sphincter weakness can result from injecting too high a dose at the base of the columella, which diffuses into the fibres of the orbicularis oris.
6Upper lip asymmetry and oral
lateral to the base of the columella can affect the upper lip levators, elongating the upper lip, blunting the contour of the philtrum and causing lip asymmetry.
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