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| BOTulInumTOxIn A | articLe It may be possible to diminish the appearance of an


idiosyncratic horizontal rhytide when it is present across the upper lip. An additional 1–2 u of onabotulinumtoxinA at the base of the columella into the depressor septi nasi by the technique described above may be necessary to further eliminate the central aspect of this horizontal upper lip rhytide. most of the time, however, injection of a soft tissue filler


is the only way to completely efface a deep, transverse upper lip wrinkle, especially when it persists after an onabotulinumtoxinA treatment of the central levators of the upper lip. In patients with extremely thin and atrophic lips, the transverse lip rhytide may not be amenable to treatments of onabotulinumtoxinA, because atrophic skin will readily crease and develop wrinkling superficially with the least bit of lip movement. The majority of patients who develop the transverse rhytides across their upper lip seem to be those over the age of 60 years, who are of light complexion (usually of skin type II and III), have spent a lot of time outdoors, and may have a history of smoking tobacco.


Complications Owing to the anatomy of the different codependent levator muscles and their attachments in both the upper lip skin and orbicularis oris, the risk–benefit ratio of treating a patient with a gingival smile is high and the potential comorbidity significant. Assistance with an electromyograph might ensure more accurate needle placement and avoid untoward results when attempting to treat an exaggerated upper gummy smile with injections of onabotulinumtoxinA. Inaccurate needle placement or overzealous dosing in


this area is subject to upper lip ptosis and an asymmetric smile, which might be coupled with buccal sphincter incompetence, difficulty producing particular sounds,


References


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4. Fagien S, Rasplado H. Facial rejuvenation with botulinum neurotoxin: an anatomical and experiential perspective. J Cosmet Laser Ther 2007; 9(Suppl 1): 23–31


5. Carruthers JD, Glogau RG, Blitzer A. Advances in facial rejuventation: botulinum toxin type a, hyaluronic acid dermal fillers and combination therapies—consensus recommendations. Plast Reconstr Surg 2008; 121(5 Suppl): 5S–30S


6. Fagien S. Botulinum toxin type A for facial aesthetic enhancement: role in facial shaping. Plast Reconstr Surg 2003; 112(5 Suppl): 6S–18S


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Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol 1996; 34(5 Pt 1): 788–97


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11. Blitzer A, Binder WJ. Current practices in the use of botulinum toxin in the management of facial lines and wrinkles. Facial Plast Surg Clin North Am. 2001; 9(3): 395–404


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septi nasi muscle in rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg. 2000; 105(1): 376–83


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17. Atamoros FP. Botulinum toxin in the lower one third of the face. Clin Dermatol 2003; 21(6): 505–12


18. Almeida AT de. Nose. In: Excel D, Almeida AT de. eds, Cosmetic Use of Botulinum Toxin. Porto Allergre, Brazil: AGE Editora, 2002


19. Pessa JE, Brown F. Independent effect of various facial mimetic muscles on the nasolabial fold. Aesthetic Plast Surg 1992; 16(2): 167–71


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Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent 1999; 11(6): 311–24


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prime-journal.com | May 2011 ❚


and an inability to move the upper lip in a full smile or pucker. The upper lip levators can be easily affected by the least amount of inadvertent diffusion of onabotulinumtoxinA.


Declaration of interest DrAnthonyVBenedetto is an investigator atBaselHealthcare, anda consultant for Medica, Liposonix, andShire. He is also a speaker for Allergan, Dusa, Johnson&Johnson, Lumenis,Osyris Medical, andMerz PharmaGroup; a stock shareholder of Allergan, Elan, andBioDelivery Systems; anda recipient of honoraria fromBrothersHealthcare.


March 2011: Cosmetic uses of botulinum toxin A in central brow frown lines. PRIME Volume 1, Issue 1


July 2011: Cosmetic uses of Botulinum toxin A in the lower face, neck, and upper chest. PRIME Volume 1, Issue 3


ACKNOWLEDGEMENTS This chapter is an edited excerpt from Botulinum Toxins in Clinical Aesthetic Practice, 2nd edition, by A. V. Benedetto. It should be clarified that while the basic concepts are presented here, further discussion and detail have been edited out to facilitate this condensed entry in the Prime journal. More details on treatment, specific cases, management of adverse outcomes, together with many more figures and detailed descriptions on treating other areas in the mid face are included in the book chapter ‘Cosmetic uses of botulinum toxin A in the mid face’ published in this book. The book is available from Informa Healthcare at www. informahealthcarebooks.com


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