The Facial Platysma and Its Underappreciated Role in Lower Face Dynamics and Contour.

BACKGROUND: The platysma is a superficial muscle involved in important features of the aging neck. Vertical bands, horizontal lines, and loss of lower face contour are effectively treated with botulinum toxin A (BoNT-A). However, its pars facialis, mandibularis, and modiolaris have been underappreciated. OBJECTIVE: To demonstrate the role of BoNT-A treatment of the upper platysma and its impact on lower face dynamics and contour. MATERIAL AND METHODS: Retrospective analysis of cases treated by an injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex. It consisted of 2 intramuscular injections into the mentalis muscle and 2 horizontal lines of BoNT-A injections superficially performed above and below the mandible (total dose, 16 onabotulinumtoxinA U/side). Photographs were taken at rest and during motion (frontal and oblique views), before and after treatment. RESULTS: A total of 161 patients have been treated in the last 2 years with the following results: frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melomental folds. CONCLUSION: The upper platysma muscle plays a relevant role in the functional anatomy of the lower face that can be modulated safely with neuromodulators.

Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations.

BACKGROUND: Although the safety profile of hyaluronic acid fillers is favorable, adverse reactions can occur. Clinicians and patients can benefit from ongoing guidance on adverse reactions to hyaluronic acid fillers and their management. METHODS: A multinational, multidisciplinary group of experts in cosmetic medicine convened the Global Aesthetics Consensus Group to review the properties and clinical uses of Hylacross and Vycross hyaluronic acid products and develop updated consensus recommendations for early and late complications associated with hyaluronic acid fillers. RESULTS: The consensus panel provided specific recommendations focusing on early and late complications of hyaluronic acid fillers and their management. The impact of patient-, product-, and technique-related factors on such reactions was described. Most of these were noted to be mild and transient. Serious adverse events are rare. Early adverse reactions to hyaluronic acid fillers include vascular infarction and compromise; inflammatory reactions; injection-related events; and inappropriate placement of filler material. Among late reactions are nodules, granulomas, and skin discoloration. Most adverse events can be avoided with proper planning and technique. Detailed understanding of facial anatomy, proper patient and product selection, and appropriate technique can further reduce the risks. Should adverse reactions occur, the clinician must be prepared and have tools available for effective treatment. CONCLUSIONS: Adverse reactions with hyaluronic acid fillers are uncommon. Clinicians should take steps to further reduce the risk and be prepared to treat any complications that arise.

Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A-Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations.

BACKGROUND: Combination of fillers and botulinum toxin for aesthetic applications is increasingly popular. Patient demographics continue to diversify, and include an expanding population receiving maintenance treatments over decades. METHODS: A multinational panel of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated guidelines with a worldwide perspective for hyaluronic acid fillers and botulinum toxin. This publication considers strategies for combined treatments, and how patient diversity influences treatment planning and outcomes. RESULTS: Global Aesthetics Consensus Group recommendations reflect increased use of combined treatments in the lower and upper face, and some midface regions. A fully patient-tailored approach considers physiologic and chronologic age, ethnically associated facial morphotypes, and aesthetic ideals based on sex and culture. Lower toxin dosing, to modulate rather than paralyze muscles, is indicated where volume deficits influence muscular activity. Combination of toxin with fillers is appropriate for several indications addressed previously with toxin alone. New scientific data regarding hyaluronic acid fillers foster an evidence-based approach to selection of products and injection techniques. Focus on aesthetic units, rather than isolated rhytides, optimizes results from toxin and fillers. It also informs longitudinal treatment planning, and analysis of toxin nonresponders. CONCLUSIONS: The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Combined treatment is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related, and that successful treatment entails identifying and addressing the primary causes of each. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications.

BACKGROUND: Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction. METHODS: A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications. RESULTS: Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action. CONCLUSIONS: The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part II: incorporating botulinum toxin into aesthetic clinical practice.

BACKGROUND: The new world of safe aesthetic injectables has become increasingly popular with patients. Not only is there less risk than with surgery, but there is also significantly less downtime to interfere with patients' normal work and social schedules. Botulinum toxin (BoNT) type A (BoNTA) is an indispensable tool used in aesthetic medicine, and its broad appeal has made it a hallmark of modern culture. The key to using BoNTA to its best effect is to understand patient-specific factors that will determine the treatment plan and the physician's ability to personalize injection strategies. OBJECTIVES: To present international expert viewpoints and consensus on some of the contemporary best practices in aesthetic BoNTA, so that beginner and advanced injectors may find pearls that provide practical benefits. METHODS AND MATERIALS: Expert aesthetic physicians convened to discuss their approaches to treatment with BoNT. The discussions and consensus from this meeting were used to provide an up-to-date review of treatment strategies to improve patient results. Information is presented on patient management and assessment, documentation and consent, aesthetic scales, injection strategies, dilution, dosing, and adverse events. CONCLUSION: A range of product- and patient-specific factors influence the treatment plan. Truly optimized outcomes are possible only when the treating physician has the requisite knowledge, experience, and vision to use BoNTA as part of a unique solution for each patient's specific needs.

Glabellar contraction patterns: a tool to optimize botulinum toxin treatment.

BACKGROUND: Botulinum toxin is a well-established treatment for dynamic glabellar lines. A previous study evaluated the existence of glabellar contraction "patterns," according to the predominance of eyebrow approximation, depression, or elevation movements, namely "U," "V," "convergent arrows," "omega," and "inverted omega." OBJECTIVES: To confirm contraction patterns in the adult population for a better treatment approach and to verify whether changes occur after repeated treatment. METHODS: Pairs of photographs-at rest and under contraction-from two groups were retrospectively analyzed: 334 adult volunteers with a predominance of specific movements, being verified and 36 previously treated individuals when they returned for re-injections. RESULTS: The five glabellar contraction patterns were confirmed. Each individual's initial pattern reappeared upon waning of the toxin effect. CONCLUSION: Interpersonal differences in facial animation are observed. Classifying glabellar wrinkles allows accurate treatment with botulinum toxin, injecting the most commonly recruited muscles with higher doses or into more sites. Muscles not so recruited are spared or injected with lower doses for more-effective and -natural results. Although botulinum toxin blockade causes recruitment of adjacent muscles, the initial muscle contraction pattern is resumed when the effect wanes.

Handling botulinum toxins: an updated literature review.

BACKGROUND: Botulinum toxin (BoNT) has been in use since the late 1970s, and over the last 20 years, its use has been extended to new indications in various areas of medicine. During these years of clinical use, some of the initial ideas have changed, and others have remained stable along with increasing experience with and knowledge about BoNTs. OBJECTIVE: To review the literature and prescribing information on all of the available products and to update the concept of handling toxins (preparations, reconstitution, storage, sterility, and dilution). METHODS: A review (not Cochrane type analysis) of the medical literature based on relevant databases (MEDLINE, PubMed, Cochrane Library, specialist textbooks, and manufacturer information) was performed. CONCLUSIONS: Many of the precautions around BoNT use, often recommended by the manufacturers, are described in the clinical literature as too restrictive. The literature suggests that toxins may be sturdier and more-resistant to degradation than previously understood.

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 BoNTA(1) (BOTOX, Allergan, Inc.) and were randomly assigned to receive BoNTA(2) (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 BoNTA(2) 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 BoNTA(1) did not compromise its efficacy in inhibiting contraction of frontalis muscle. CONCLUSION: BoNTA(2) has a greater area of diffusion in the forehead than BoNTA(1), even with identical injection volumes. This may hinder accurate localization of clinical effect, thereby increasing the potential for adverse effects.