| boTulInuM ToxIn A | ARticle


Dosing The patient can be treated more comfortably in the semi‑reclined rather than upright position. Approximately 2–4 u of onabotulinumtoxinA can be injected into each site on the anterior chest wall in a variety of treatment patterns. The key to a successful outcome is to have the toxin diffuse throughout the entire anterior expanse of the upper chest wall38


. Injections should be applied superficially into the


deep dermis or at the dermo‑subcutaneous junction. The area to be treated is outlined as either an upside down isosceles or equilateral triangle, the apex of which is at a point over the middle of the xiphoid process of the sternum, and the base is an imaginary line that connects two points placed over the middle of both clavicles38


. Approximately 2–4 u of onabotulinumtoxinA are


injected into the dermo‑subcutaneous plane at multiple sites roughly 1.5–2 cm apart. The total dose injected should range from 20–50 u of onabotulinumtoxinA (average is 35 u) depending on the overall strength of the platysma, the depth of the wrinkling, and the size and expanse of the anterior chest wall. Some chests will require anywhere from 6–12 injection sites to be successful.


Outcomes A smoothing of the surface of the central mid to lower décolletage usually occurs within 1–3 weeks of treatment. The diminution of chest wrinkling begins more slowly compared with facial treatment, and it may be effective for only 2–3 months. Widespread diffusion of the injected toxin is necessary to achieve total coverage and complete reduction in the wrinkling of the skin surface of the upper chest wall. Therefore, injections in the upper chest wall are preferably performed with high volumes of low concentration botulinum toxin A6


. References


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2. Standernig S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th edn. USA: Elsevier, 2008


3. Semchyshyn N, Sengelmann RD. Botulinum toxin A treatment of perioral rhytides. Dermatol Surg 2003; 29(5): 490–5


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


5. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003; 29(8): 802–9


6. Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: adjunctive use in facial aesthetic surgery. Plast Reconstr Surg 1999; 103(2): 701–13


7. Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg 2003; 29(5): 468–76


8. Klein AW. Complications and adverse reactions with the use of botulinum toxin. Seminars Cut Med Surg 2001; 20(2): 109–20


9. Alam M, Dover JS, Klein AW, Arndt KA. Botulinum a exotoxin for hyperfunctional facial lines: here not to inject. Arch Dermatol 2002; 138(9): 1180–5


10. Mazzuco R. Perioral wrinkles. In: Hexel D, de


Almeida AT. eds, Cosmetic Use of Botulinum Toxin. Porto Allegre, Brazil: AGE Editora, 2002


11. Rubin LR. The anatomy of a smile: its importance in the treatment of facial paralysis. Plast Reconstr Surg 1974; 53(4): 384–7


12. Benedetto AV. Asymmetric smiles corrected


by botulinum toxin serotype A. Derm Surg 2007. 33(S1): S32–S36


13. Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock TA. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol 2011. 32(1): 1–7


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15. Biglan AW, Burnstine RA, Rogers GL,


Saunders RA. Management of strabismus with botulinum toxin A. Ophthalmology 1989; 96(7): 935–43


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Blitzer A, Brin MF, Green PE, Fahn S. 17. Carruthers J, Carruthers A. Botulinum toxin


(botox) chemodenervation for facial rejuvenation. Facial Plast Surg Clin North Am 2001; 9(2): 197–204


18. Loos BM, Mass CS. Relevant anatomy for


botulinum toxin facial rejuventation. Facial Plast Surg Clin North Am 2003; 11(4): 439–43


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mentalis muscle dysfunction. Arch Facial Plast Surg 2001; 3(4): 268–9


compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007. 119(7): 2219–27


21. Spósito MM. New indications for botulinum toxin type A in cosmetics: mouth and neck. Plast Reconstr Surg 2002; 110(2): 601–11


22. Levy PM. The ‘Nefertiti lift’: A new technique


for specific re-contouring of the jawline. J Cosmet Laser Ther 2007; 9(4): 249–52


23. Cardoso de Castro C. The anatomy of the platysma muscle. Plast Reconstr Surg 1980; 66(5): 680–3


24. Pogrel MA, Schmidt BL, Ammar A, Perrott


25. Hoefflin SM. The platysma aponeurosis. Plast Reconstr Surg 1996; 97(5): 1080


26. Janfaza P, Nadol JB, Galla HJ et al. Surgical Anatomy of the Head and Neck. Philadelphia: Lippincott Williams and Wilkins, 2001


27. Cardoso de Castro C. The changing role of


platysma in face lifting. Plast Reconstr Surg 2000; 105: 764–75


28. Brandt FS, Boker A. Botulinum toxin for rejuvenation of the neck. Clin Dermatol 2003; 21(6): 513–20


DH. Anatomic evaluation of anterior platysma muscle. Int J Oral Maxillofac Surg 1994; 23(3): 170–3


29. Carruthers A, Carruthers J. Clinical


indications and injection technique for the cosme tic use of botulinum A exotoxin. Dermatol Surg 1998; 24(11): 1189–94


30. Matarasso A, Matarasso SL, Brandt FS et al.


Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg 1999;103:645–52


31. Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol Surg 1998; 24(11): 1232–4


32. Blitzer A, Binder WJ. Cosmetic uses of


botulinum neurotoxin type A: an overview. Arch Facial Plast Surg 2002; 4(4): 212–20


33. Hoefflin SM. Anatomy of the platysma and lip depressor muscles. A simplified mnemonic approach. Dermatol Surg 1998; 24(11): 1225–31


34. Blitzer A, Binder WJ, Aviv JE Keen MS, Brin


MF. The management of hyperfunctional facial lines with botulinum toxin: a collaborative study of 210 injection sites in 162 patients. Arch Otolaryngol Head Neck Surg 1997; 123(4): 389–92


35. Dayan S. Facial Plastic Surgery Clinics of


North America: Botox. Philadelphia: WB Saunders Company, 2003


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prime-journal.com | July 2011 ❚


Treatment implications when injecting the chest


1 Injections of high-


concentration botulinum toxin A in the upper ‘V’ of the anterior chest wall can suppress the fine surface wrinkling of the skin of that area


2Induction of effect in


difficulty with deep inspiration or with adducting the upper extremities.


the upper chest takes longer and lasts for a shorter amount of time compared to facial injections.


3Overdosing can cause volume, low


Complications The most common side‑effect reported is inadequate clinical results owing to insufficient dosing. Additional adverse sequelae include a reduction in upper extremity muscle strength, especially on adduction and internal rotation. If botulinum toxin A is injected too deeply and at higher doses, unintended weakening of the intercostal musculature can occur, which may interfere with deep respiration. The clinical results of pectoral platysma weakening can take up to 15 days or longer to occur; a much slower onset of effect compared to that which occurs after injections of facial muscles37


.


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 lower face, neck and chest


are included in the book chapter ‘Cosmetic uses of botulinum toxin A in the


lower face, neck, and upper chest’ published in this book. The book is available from Informa Healthcare at www. informahealthcarebooks.com


41


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