ARticle | boTulInuM ToxIn A | administered per session. In the properly selected
patient, botulinum toxin A also can be used to reduce the appearance of vertical neck bands and cords15–19, 26
. In those
with extensive cutaneous laxity and flaccid platysmal cords, injections can actually cause the patient’s appearance to worsen. With the patient contracting the platysma, grasp the
platysmal band between the thumb and index finger of the non‑dominant hand. Inject 2–3 u of onabotulinumtoxinA into each injection site along the vertical extent of the band, starting approximately 2 cm below the inferior border of the mandible centrally in the submental area, and approximately 1 cm below the inferior border of the mandible, lateral to the origin of the depressor anguli oris. This technique avoids diffusion of botulinum toxin into the lower fibres of the lip depressors and may prevent unexpected distortions of the chin and functional disturbances of the lower lips. Repeat each injection at intervals of 1.5–2 cm, descending down the neck toward the border of the clavicle28
. Keeping the injections as
superficial as possible will avoid post‑injection ecchymoses resulting from puncturing the superficial muscular vasculature. Most patients require three to five injection points to treat
a platysmal band adequately; some may require more depending on the length of the neck. It is advisable to inject no more than 10–15 u along the vertical extent of each cervical platysmal band for a total of 30–50 u per treatment session when two or three neck bands are treated29
. When
more than two platysmal bands are present in the neck, the other two or more platysmal bands should be treated at another treatment session 2–4 weeks later.
Outcomes Relaxation of a hypertrophic platysma with diminution of horizontal neck lines and vertical bands will occur 5–7 days after treatment. The effects can last anywhere from 3–5 months, depending on the precision of the injections, the strength of the platysma, and the frequency and intensity of the patient’s neck movements. usually, patients who are too young for rhytidectomies, or older patients who have had rhytidectomies, will have the best results when there is reasonably tight cutaneous elasticity and minimal ptosis of subplatysmal fat and soft tissue. Treatment with botulinum toxin A has been beneficial
in preparing a patient for submental liposuction as, by relaxing the neck bands, a more even draping of the anterior neck skin can be achieved following liposuction. When there is a significant amount of fat herniation from in between the two lateral sheets of platysma in certain patients, along with submandibular fat occupying the submental area, liposuction with or without platysmaplasty are the only treatments that will be corrective. In those who experience suboptimal results with
residual banding and asymmetric draping of the anterior neck skin after rhytidectomy, injections of botulinum toxin A can normalise these unwanted outcomes. The additional benefit of a slight elevation of the lower lip and buccal commissures and a tightening of lower cheek jowels has
40 ❚ July 2011 |
prime-journal.com
Treatment implications when injecting the neck
1 Superficial intradermal
large amounts can cause varying degrees of dysphagia and an inability to raise the head and keep it upright.
2Deep injections of 3Injecting the superior,
mandibular fibres of the platysma can affect the corners of the mouth, lower lip, chin and inferior border of the mandible because of the interdigitation of platysmal fibres into the mimetic muscles of the lower face.
lax, redundant skin and attenuated platysma fibres that are separated and form flaccid neck bands and cords, the toxin may enhance rather than diminish their appearance.
4In older patients with 5Injections of
botulinum toxin cannot correct the herniation of
injections of botulinum toxin A can diminish horizontal wrinkles and vertical bands.
been known to occur for quite some time31–33 . This effect of
lower face‑lifting takes place when the toxin diffuses from the fibres of the upper platysma pars mandibularis into the decussating fibres of the depressor anguli oris and the platysma, immediately subjacent to the body of the mandible during injections of platysmal bands31–33
.
Complications Treatment of horizontal rhytides and vertical bands is usually very safe, and there is a low incidence of untoward sequelae. When they do occur, however, they are usually the result of improper technique and overzealous dosing. Since the underlying muscles of deglutition, phonation, and neck flexion are cholinergic in origin, overdosing can result in xerostomia, dysphagia, dysphonia, dysarthria, and neck weakness8, 34
. Injections of more than 50 u of
onabotulinumtoxinA increase the risk for temporary hoarseness and dysphagia. In patients treated for cervical dystonia in whom over
200 u of onabotulinumtoxinA are injected into the strap muscles of the neck during one treatment session, dysphagia, hoarseness, dry mouth, and flu‑like symptoms have been observed35, 36
. When botulinum toxin A is injected to reduce
platysmal banding and transverse rhytides, mild and transient neck discomfort can occur for 2–5 days, with only a rare occurrence of neck weakness30
. only one patient out of
1500 in a multiple centre study experienced clinically significant dysphagia, which spontaneously resolved within 2 weeks. Profound dysphasia was reported in one patient when more than 75–100 u were used to treat platysmal bands during one session37
. Common side‑effects include transient oedema and
subplatysmal fat or reduce the fullness of excessive amounts of submental or submandibular fat.
erythema, both of which usually resolve within 1–2 days. When botulinum toxin A injections are placed 1–2 cm beneath the inferior margin of the mandible centrally, fibres of the depressor labii inferioris can be weakened by diffusion, causing a dysfunction of the lower lip integrity and sphincteric balance.
Upper chest wrinkling The décolletage reveals the tell‑tale skin changes caused by time spent in the sun. Inelastic, sagging facial skin that has been rejuvenated to a more youthful appearance by redraping and resurfacing techniques, and with soft tissue fillers and implants, will be marred by the appearance of wrinkling on the upper chest. both static and dynamic wrinkling may coexist here. When they do, the person appears deceptively older, spoiling the youthful impression portrayed by a wrinkle‑free face and neck.
Functional anatomy The platysma is a thin, superficial, broad sheet of muscle of varying prominence that originates from the fascia, covering part of the upper pectoralis major and deltoid. In certain patients the platysma can originate lower than the second, and as far down as the fourth to the sixth, intercostal space. If contraction of the platysma in these patients is hyperkinetic and constant, excessive horizontal and vertical wrinkling of the central, mid to the lower décolletage can occur38
.
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