Advancement of the frontalis muscle for ptosis of the brow associated with essential blepharospasm.

We evaluated our results of advancement of the frontalis muscle to correct brow ptosis associated with blepharospasm in five patients who had difficulty opening their eyelids as a result of ptosis even after injections of botulinum toxin. The frontalis muscle was retracted inferiorly and connected directly to the skin of the eyebrow. Postoperatively the level of the eyebrow was raised above the superior orbital rim in all cases during the observation period (4 to 15 months). Although the operation did not improve muscle spasms, it successfully shortened the duration of involuntary closure of the eyelid. The only postoperative complication was lymphoedema of the eyelids. Results of postoperative injection of botulinum toxin were satisfactory. Advancement of the frontalis muscle corrects brow ptosis without major complications, and is complementary to injection of botulinum toxin.     

Botulinum Toxin Type B (MYOBLOC) Versus Botulinum Toxin Type A (BOTOX) Frontalis Study: Rate of Onset and Radius of Diffusion

BACKGROUND: Botulinum toxin types A and B can improve the appearance of facial wrinkles. Differences in the time until onset and the degree of diffusion have been observed anecdotally, but no direct comparative studies have been done. OBJECTIVE: To compare the rate of onset and the radius of diffusion of botulinum toxin types A and B in the rhytides of the forehead. METHODS: Adults with symmetrical moderate to severe forehead wrinkles at full contracture received botulinum toxin type A (BOTOX; 5 U) on one side of the forehead and type B (MYOBLOC; 500 U) on the other side. Photographs taken at rest and full frontalis contracture were analyzed by computer, and a time-lapse motion picture was created. Radius of diffusion and time until full effect were measured. RESULTS: Botulinum toxin type B had a slightly faster onset of action than type A. All patients responded to type B quickly, whereas some had a delayed response to type A. A greater radius of diffusion was consistently observed with botulinum toxin type B, as measured by the greater area of wrinkle reduction at the doses used. CONCLUSIONS: In this comparative study of patients with symmetrical forehead wrinkles, botulinum toxin type B produced a greater area of diffusion and a more rapid onset of action than type A.     

A型肉毒毒素在额部软组织扩张中的应用

目的：探讨A型肉毒毒素辅助额部软组织扩张的作用效果。方法：在置入150ml扩张器前，左右平分额部扩张器置入区，于一侧额肌内注射A型肉毒毒素，对侧注射生理盐水作为对照，采用双盲法测定扩张器注水量及注水时间，并对比两侧注水时的疼痛程度，观察临床效果。结果：5例扩张器均给予超量注水，平均注水量216ml，平均注水时间7周。5例均于扩张器注水过程中在对照侧出现局部疼痛不适，注射A型肉毒毒素侧未感到疼痛，并且肿胀感明显低于对照侧。扩张皮瓣转移修复时见注射A型肉毒毒素侧额肌厚度明显小于对照侧，皮瓣较薄，转移后形态较好，术后皮瓣均完全成活，无坏死。结论：在额部软组织扩张时，应用A型肉毒毒素注射于额肌，使额肌松弛，可使额部扩张阻力减小，扩张时间缩短，减轻扩张时的局部疼痛及肿胀感，使皮瓣更薄，有利于获得更好的修复效果。     

Auswirkung von Botulinumtoxin an der Stirn auf die Brauenposition

Background

Chemodenervation with botulinum toxin for esthetic reduction of wrinkles of the forehead is one of the most commonly performed interventions in esthetic surgery worldwide. The safety and effectiveness has been proven in a multitude of studies; however, only a few studies have objectively measured the results of treatment by chemodenervation of the glabella and the occipitofrontal muscle and given recommendations for optimization of treatment in the various patient groups.

Material and methods

After describing the relevant muscular anatomy of the glabella and the forehead, the routine regimens for botulinum toxin treatment of frown wrinkles and horizontal forehead wrinkles are presented. The alterations in the exact eyebrow positions in ten female subjects before and after botulinum toxin treatment of either the glabella alone or the glabella and occipitofrontal muscle were measured using 3D surface scans of the face.

Results

Even after treatment of the glabella alone there was a trend to sagging of the medial eyebrow which became stronger and laterally extended after inclusion of the occipitofrontal muscle. This effect increased with the age of the subject.

Conclusion

Before treatment with botulinum toxin an exact evaluation of the position of the forehead, eyebrows and the proportion of the muscular stabilization is necessary in order to achieve an optimal adjustment of the chemodenervation to the individual prerequisites of patients, particularly in patients with (compensated) brow ptosis.     

Diffusion and Short-Term Efficacy of Botulinum Toxin A After the Addition of Hyaluronidase and Its Possible Application for the Treatment of Axillary Hyperhidrosis

BACKGROUND: Botulinum toxin adequately treats hyperkinetic facial lines and hyperhidrosis. Higher doses of botulinum toxin appear to enhance efficacy and longevity possibly through greater evenness of diffusion; however, recurrent treatments with higher doses are expensive. OBJECTIVE: To admix botulinum toxin with hyaluronidase and to test whether there is maintenance of efficacy, a spread of effect, and possibly a decrease in required dose compared with botulinum toxin. METHODS: Six patients participated in a double-blinded side-to-side comparison pilot study with photographic analysis for frontalis overactivity and Minor's iodine and gravimetric testing for axillary hyperhidrosis. RESULTS: Initial efficacy of botulinum with admixed hyaluronic acid appeared maintained with possibly increased diffusion when hyaluronic acid is added. No difference was evident on short-term review of patients treated with 50 U of botulinum in one axilla compared with the contralateral side injected with 25 U with admixed hyaluronidase. CONCLUSION: There may be a role for hyaluronic acid in aiding diffusion and decreasing the required dose of botulinum toxin in hyperhidrosis axillaris.     

Long-term prospective follow-up of botulinum toxin treatment for facial rhytides

Some wrinkles and unsightly facial expressions are due to hyperactivity of the underlying facial musculature. Clostridium botulinum type A exotoxin reversibly paralyzes selected muscles and is a safe, helpful adjunct to many other treatments for facial rejuvenation. Fifty-two patients were treated and all data recorded in a prospective fashion. Only areas requested by the patient were treated. The dosage and dilution given in each area were carefully noted and all patients had pretreatment and posttreatment photographs. The effect of botulinum toxin injections on the horizontal brow rhytides was recorded by measuring the distance from the frontal hairline to the superior edge of the eyebrow in the mid-pupillary line. Patients were followed for one to three years (mean 16.3 months). One patient was not responsive to botulinum toxin in spite of repeated injections. Three further patients required touch-up injections two weeks after the initial treatment due to a weak initial response. Repeat injections were required every three to six months (mean 4.05) to maintain the desired improvement. Asymmetry of the brow was seen in two patients and corrected with further administration of botulinum toxin. Twenty-five patients had their forehead rhytides injected and the appropriate measurements taken. Brow ptosis occurred in 22 of the 25 patients and varied 1–6 mm with a mean value of 2.3 mm. This difference was statistically significant (paired t-test p <0.001). Two patients reported dryness and flakiness of the frontal area after injections. No cases of eyelid ptosis or hypersensitivity were seen. Botulinum toxin injections are safe and all undesired effects are reversible. Great care has to be taken not to aggravate the degree of brow ptosis. Injection of the forehead depressors minimizes the risk of brow ptosis. Careful planning of injection sites and doses avoids a mask-like upper face. The use of botulinum toxin provides a useful adjunct to laser and surgical procedures for facial rejuvenation.     

A型肉毒毒素治疗面部皱纹效果观察

目的:探讨A型肉毒毒素行面部老化治疗中的最佳注射点位,探讨A型肉毒毒素应用的特点,适应证及并发症等。方法:分析2009年8月至2012年12月之间198例面部老化患者行A型肉毒毒素注射治疗的临床资料,根据注射点位的不同,术后随访观察额纹、鱼尾纹、眉间纹等处皱纹的改变情况。结果:按实验中的点位注射,198例患者中180例效果显著,18例自觉效果不够理想,无患者出现眉下垂、睑外翻等并发症,也无晕厥休克等严重过敏性反应。结论:应用A型肉毒毒素治疗面部老化,治疗效果肯定,治疗过程安全,可扩大A型肉毒毒素应用于面部老化治疗的范围,也可采用多点位、小剂量注射可起到个性化去皱的效果。     

Botulinum Toxin A Treatment of Perioral Rhytides

BACKGROUND: Botulinum toxin A is well documented as a useful therapy for smoothing dynamic facial rhytides of the upper face. Most controlled studies have focused on the treatment of glabellar frown lines, horizontal forehead lines, and crow's feet. Reports of botulinum toxin A use in the lower face are few and anecdotal. OBJECTIVE: We present our experience using botulinum toxin A in the lip as a treatment of vertical perioral rhytides, which resulted in the added cosmetic benefits of lip eversion and enhanced lip fullness. METHODS: Eighteen patients were injected with botulinum toxin A into the vertical lip rhytides. The effect of treatment was evaluated at 2 to 3 weeks after procedure. RESULTS: Smoothening of hyperfunctional lines and upper lip fullness/eversion is observed in patients treated with perioral botulinum toxin A injections; 72% of patients continued treatment. CONCLUSIONS: In select patients, perioral botulinum toxin A results in amelioration of perioral rhytides and enhancement of lip fullness and lip eversion.     

Questioning the need to use Botox within 4 hours of reconstitution: a study of fresh vs 2-week-old Botox

OBJECTIVE: To determine whether injection with botulinum toxin type A (Botox; Allergan Inc, Irvine, California) reconstituted with preservative-free saline (0.9% isotonic sodium chloride) after 2-week cold storage in a refrigerator (4 degrees C) or freezer (-20 degrees C) is less efficacious than injection with freshly reconstituted Botox. METHODS: We conducted a prospective, double-blind, randomized controlled trial at an academic facial plastic surgery practice with 40 volunteers for treatment of horizontal forehead rhytids, each acting as his or her own control. In a blinded fashion each subject received freshly reconstituted Botox (control) on one side of the forehead (frontalis muscle) and 2-week-old reconstituted Botox (experimental) stored at 4 degrees C (refrigerated) or stored at -20 degrees C (frozen) on the other side. The right and left forehead movement was measured and photographed at rest and during maximum contraction of the frontalis muscle prior to Botox administration and on follow-up days 14, 30, 60, 90, and 120 after injection. Each participant also completed a questionnaire regarding right and left forehead movement prior to injection and at each follow-up visit. RESULTS: No significant difference was noted for any subject in the timing of onset or duration of action or the measurable reduction of forehead movement between the fresh and 2-week-old refrigerated Botox or between the fresh and 2-week-old frozen Botox. The subjects had a gradual return of muscle function over the 4-month follow-up period. CONCLUSIONS: No measurable difference was found in the potency or duration of efficacy of Botox in the treatment of forehead rhytids after 2 weeks of refrigeration or freezing compared with fresh reconstituted Botox. When Botox, fresh or stored, is given at an adequate dose to cause full paralysis of the desired muscle, the duration of the muscle paralysis is dependent on the physiologic rate for the motor nerve to reestablish neural transmission.     

局部注射少量A型肉毒毒素治疗上半面部皱纹的临床研究

目的：观察局部注射少量A型肉毒毒素（BTXA）去除上半面部皱纹的临床疗效。方法：应用A型肉毒毒素的198例患者,其中眉间纹65例,鱼尾纹80例,额纹20例,鼻背部皱纹33例。所有患者行局部多点注射A型肉毒毒素,浓度为4U/0.1ml,并根据不同的患者调整剂量和浓度。记录患者疗效、维持时间与不良反应。结果：A型肉毒毒素治疗面部上三分之一皱纹有效率为100%,显效率94.4%。肌肉麻痹的效果通常持续3～6个月不等,不良反应主要为4例上睑下垂,3例局部水肿和4例青紫,各占2.0%、1.5%和2.0%。上述症状于3～10内自行完全消失。结论：A型肉毒毒素局部注射治疗面部上三分之一皱纹起效迅速、无创伤、简便易行。     

内镜额部除皱术结合传统切开法除皱的效果

目的探讨内镜除皱术与传统除皱术相结合的治疗方式及效果。方法仅存在额部皱纹、眉间纹及眉下垂者采用内镜额部除皱术,切除或切断皱眉肌、降眉肌和额肌,必要时结合额部皮瓣上提悬吊技术即可;如同时存在中下面部皮肤老化、松弛下垂,则内镜额部除皱术尚需结合传统切开法的中面部或中下面部除皱术,做浅表肌腱膜系统（sMAs）筋膜的折叠或切除缝合,以及多余皮肤的切除剪裁。结果104例采用额部内镜除皱术,均取得良好的除皱和眉提升效果。并发症较少而轻微,包括表情肌去除部位的轻度凹陷、额部皮肤麻木、发际线轻微后移、皱纹去除不彻底等。无面神经颞支损伤等严重并发症发生。其中84例存在中下面部皮肤松弛下垂,在做内镜额部除皱的同时行耳前切口的传统除皱术,明显改善中下面部的皮肤老化,并使面部上下的年轻化协调一致。结论内镜额部除皱术设计合理、操作安全、效果明确,是一项切口小、损伤轻的微创技术,符合整形外科的发展趋势。对于同时存在有中下面部皮肤松弛者,如能结合传统切开法除皱术,面部年轻化的整体效果可进一步优化。     

Measurement of the Anatomic Position of the Corrugator Supercilii

Objective. To standardize the location of the corrugator supercilii by using known facial landmarks.
Methods. The corrugator supercilii points of origin, insertion, and maximal muscle thickness were measured relative to the nasion and supraorbital notch in 21 cadavers. Comparisons of measurements between male and female cadavers were performed using a two-tailed t-test.
Results. The location of the corrugator supercilii was variable but was not significantly different between males and females. From the nasion, the mean point of origin was 4 mm lateral and 6 mm superior, the mean point of insertion was 33 mm lateral and 16 mm superior, and the mean maximal muscle thickness was 16 mm lateral and 10 mm superior. At their point of greatest thickness, most corrugators were found to lie below the upper border of the superciliary arch.
Conclusions. There is variability in the location of the corrugator supercilii that is not gender dependent. When injecting botulinum toxin into the corrugator supercilii, it might be advantageous if the lower forehead skin of the brow is elevated, thus allowing for more precise injection. This may achieve weakness of the targeted muscle with lower doses of botulinum toxin, thus lessening the risk of eyelid and brow ptosis.     

Long-term effects of botulinum toxin on neuromuscular function

BACKGROUND: Recent reports indicate increased incidence of Clostridium botulinum infections, particularly among drug abusers and tissue allograft recipients. Botulinum toxin also has potential application in biochemical warfare. The neurotoxin-induced paralysis often requires mechanical ventilation with and without muscle relaxants. The authors investigated the long-term effects of botulinum toxin on muscle function, expression of nicotinic acetylcholine receptors (nAChRs), and their interaction with muscle relaxant, atracurium. METHODS: Rats (n=30) were injected with varying doses (0.625, 2.5, and 10 U) of botulinum toxin into the tibialis muscle. Control animals (n=9) received an equivalent volume of saline. At 128 days after injection, neuromuscular function, pharmacodynamics of atracurium, and nAChRs were evaluated. RESULTS: Nerve-evoked tensions, including tetanic tension and muscle mass, were decreased on the toxin-injected side in a dose-dependent manner relative to saline-injected controls as well as the contralateral side. Specific muscle tension and specific tetanic muscle tension (tensions/muscle mass) were not reduced. The ED10 of atracurium was reduced, the ED50 was unchanged, and the ED90 was increased in the highest (10-U) dose of toxin group. The atracurium plasma concentration to maintain a steady state 50% paralysis was significantly reduced in the 10-U toxin group. The nAChR concentrations in the tibialis muscle were significantly increased in a dose-dependent manner in all experimental groups. CONCLUSION: Botulinum toxin causes dose-dependent long-term neuromuscular changes. The loss of tension generating capacity is almost exclusively related to muscle atrophy, because the specific tension did not change. The decreased ED10, unaltered ED50, and increased ED90 to atracurium suggest its interactions with different isoforms of receptors having varying sensitivity to atracurium. The absence of fade, despite the persistent botulinum toxin-induced denervation (increased nAChRs), suggests that the up-regulated nAChRs may have compensated for the prejunctional effects of botulinum toxin.     

A型肉毒毒素辅助额部皮肤软组织扩张的实验研究

目的：通过动物实验明确A型肉毒毒素对额部皮肤软组织扩张的辅助扩张效果。方法：于小型猪胸腹部两侧皮肌下置入扩张器,一侧皮肌注射A型肉毒毒素,另一例注射生理盐水,对比两侧扩张器的扩张前基础囊内压、每次扩张器注水量及扩张时间。结果：实验组平均注水时间为（28±4．5）天,对照组平均注水时间为（42±3．5）天,扩张时间平均缩短（13±5．5）天（P〈0．01）;实验组平均注水（8±0．5）次,平均每次注水量为（26．1±3．5）ml;对照组平均注水（12±0．8）次,平均每次注水量为（16．7±0．9）ml（P〈0．01）;实验组平均基础囊内压为（3．4±0．6）mmHg,对照组平均基础囊内压为（10．1±0．8）mmHg（P〈0．01）。结论：注射A型肉毒毒素于猪胸腹部皮肌,可使放置于皮肌下的扩张器扩张阻力减小,扩张器基础囊内压下降,每次注水量增加,扩张时间缩短,对临床中应用A型肉毒毒素辅助额部皮肤软组织扩张有重要的指导意义。     

A型肉毒毒素辅助额部皮肤软组织扩张的生物力学研究

目的:通过动物实验探讨A型肉毒毒素注射后额部扩张皮瓣的生物力学性能的变化规律,以期为临床应用提供理论依据。方法:选用白色实验小型猪,在其胸腹部两侧用作网格样标记,一侧注射A型肉毒毒素,对侧注射生理盐水对照,两侧置入200ml扩张器,注水完成后切取全层扩张皮瓣作为试件,在I ns t r on4302万能材料试验机上对皮瓣试件进行应力-应变、应力松弛和蠕变实验。结果:实验组皮瓣的粘弹性比对照组的好,更接近于未扩张皮瓣;在同样的松弛时间内,实验组皮瓣比对照组更容易松弛;在相同的应力作用下,相同的时间内,实验组皮瓣的蠕变量要小于对照组。结论:注射A型肉毒毒素后,可以使扩张皮瓣的粘弹性增强,更接近于未扩张皮瓣,扩张器注水量增加,注水间隔缩短,在相同注水量下扩张面积增加。     

Pilot Study Comparing the Diffusion of Two Formulations of Botulinum Toxin Type A in Patients with Forehead Hyperhidrosis

BACKGROUND Different formulations of botulinum toxin type A (BoNTA) may have different diffusion characteristics.
OBJECTIVE The objective was to compare the diffusion characteristics of two formulations of BoNTA.
MATERIALS AND METHODS A total of 20 patients with forehead hyperhidrosis received four injections of BoNTA in their forehead (one medial and lateral injection of one formulation randomly assigned to one forehead side, one medial and lateral injection of the other formulation to the other forehead side). Patients received 3 U/injection of BoNTA¹ (BOTOX, Allergan, Inc.) and were randomly assigned to receive BoNTA² (Dysport, Ipsen Ltd.) at a dose ratio of 1:2.5, 1:3, or 1:4. The area of anhidrosis was highlighted using iodine and starch and determined by software from standardized photography.
RESULTS During the 6 months after treatment, the area of anhidrosis was larger with BoNTA² in 93% (195/210) of medial-medial or lateral-lateral comparisons of the two products and at all dose ratios. The smaller area of anhidrosis with BoNTA¹ did not compromise its efficacy in inhibiting contraction of frontalis muscle.
CONCLUSION BoNTA² has a greater area of diffusion in the forehead than BoNTA¹, even with identical injection volumes. This may hinder accurate localization of clinical effect, thereby increasing the potential for adverse effects.     

Optimal forehead rejuvenation. Combining endoscopy-peel-botulinum toxin

The combining of a traditional resurfacing technique (trichloracetic or phenol peel) with 2 recent technological advances (endoscopic forehead plasty, botulinum toxin) may enhance the forehead rejuvenation in a more natural way. The disappointing results of some of our earlier results on a serie of 70 consecutive foreheadplasties can probably be attributed to the weakness of the suspension through percutaneous sutures. This has been remedied since 1998 by the systematic use of transosseous suspensions. The growing success of botulinum toxin explains the noticeable decrease of endoscopic surgery. This type of procedure is now used to correct significant frontal ptosis requiring an uplifting of no more than 1,5 cm, thereby avoiding the unnatural results encountered in many publications. Some benefits can be obtained by the way of a transpalpebral approach without using the endoscope; nowadays, upper blepharoplasties are almost systematically done in the majority of our cases in order to obtain the most natural result. Light peels and botulinum toxin injections can maintain this result relatively easily.     

Three-Dimensional Analysis of Forehead Wrinkles

It is important to understand the anatomical characteristics of forehead wrinkles in order to perform a forehead lift. This study aimed to elucidate the mutual relationships among tissues composing the forehead using computer software that enables the stereoscopic observation of the tissues studied in arbitrary directions. The specimens were obtained from five cadavers and prepared in serial sagittal sections. Three-dimensional images were prepared by inputting the forehead wrinkle data obtained from serial sagittal sections. Consequently, the forehead skin was found to be fixed to the superficial galea aponeurotica through fibrous septa, suggesting that movement of the frontalis muscle would be transmitted to the skin, not through the fibrous septa alone, but from the superficial galea aponeurotica closely attached to the frontalis muscle through the fibrous septa. Since the forehead muscles exhibit a stereostructure where the corrugator supercilii muscle supports three superficial forehead muscles, including the frontalis muscle, the orbicularis oculi muscle, and procerus muscle on the periosteal side, it was presumed that a sufficient effect would not be attained unless the corrugator supercilii muscle was operated on concurrently in conjunction with these muscles during a procedure involving the superficial forehead muscles in a forehead lift. Based on the findings from the three-dimensional images obtained, effective tissue treatments could be achieved by performing (1) dissection between the superficial galea aponeurotica and the frontalis muscle, (2) dissection between the deep galea aponeurotica and the periosteum, and (3) a procedure incorporating the forehead muscles in order.     

A Randomized Pilot Study Comparing the Action Halos of Two Commercial Preparations of Botulinum Toxin Type A

BACKGROUND The determination of the action halos of botulinum toxin type A aids in targeting specific muscles and/or sweat glands, thereby preventing the occurrence of side effects.
OBJECTIVES The objective of this study was to compare the action halos of two commercial preparations of botulinum toxin type A, Dysport (Ipsen, Slough, UK) and BOTOX (Allergan, Irvine, CA).
MATERIAL AND METHODS Eighteen volunteers received applications of both products into randomized sides of the frontalis muscle. Equivalent doses of 5U of Dysport and 2U of BOTOX were injected using the same technique, in the same volume (0.02mL), and at a controlled depth. Twenty-eight days later, clinical and photographic assessments were performed.
RESULTS All the areas around the injected points were regular, round, or slightly oval and showed similar effects in the muscles and sweat glands. No statistically significant differences were observed between the mean sizes of the diameters of the halos produced by the two products.
CONCLUSION Injections of Dysport and BOTOX at an equivalence ratio of 2.5:1U, respectively, applied at the same volume and depth, using the same technique resulted in similar action halos with regard to muscular and sweat gland activity. Both products seem to be safe and very predictable.