Facial Plast Surg Clin N Am 11 (2003) 515 520

New procedures in facial plastic surgery using botulinum toxin A

Howard D. Stupak, MDa, Corey S. Maas, MDa,b,*
a Division of Facial Plastic Surgery, Department of Otolaryngology - Head and Neck Surgery, University of California at San Francisco, 400 Parnassus Avenue, San Francisco, CA 91143-0342, USA b The Maas Clinic, 2400 Clay Street, San Francisco, CA 94115, USA

Botulinum toxin is a potent neurotoxin that is produced by the bacterium Clostridium botulinum. The agent causes muscle paralysis by preventing the release of acetylcholine at the neuromuscular junction of striated muscle. Botulinum toxin A (Botox, Allergan Inc., Irvine, California) is the most potent of seven distinct toxin subtypes that are produced by the bacterium [1]. The toxin was first used clinically in the treatment of strabismus caused by hypertonicity of the extraocular muscles [2]. The toxin was subsequently described in the treatment of multiple disorders of muscular spasticity and dystonia [3,4]. In treating patients with Botox for blepharospasm, Carruthers and Carruthers [5] noticed an improvement in glabellar rhytids. This ultimately led to the introduction and development of Botox as a mainstay in the treatment of hyperfunctional facial lines. Since its approval by the U.S. Food and Drug Administration for the treatment of facial rhytids in 2002, botulinum toxin A has exploded onto the marketplace and into widespread national use. When treating facial rhytids, most physicians are most comfortable using Botox in the upper third of the face where results are the most well-described, noticeable, and predictable [6]. Forehead, glabellar, and periocular rhytids are the most frequently treated facial regions, and excellent results have been documented. [6,7] Indications for alternative uses for Botox in facial plastic and reconstructive surgery are expanding. These include a variety of well-established procedures

that use Botox as an adjunctive agent to enhance results. In addition, Botox injection is finding increased usefulness as an independent modality for facial rejuvenation and rehabilitation. The agent is used beyond its role in facial rhytids as an effective agent in the management of dynamic disorders of the face and neck. Botox injection allows the physician to precisely manipulate the balance between complex and conflicting muscular interactions, thus resetting their equilibrium state and exerting a clinical effect. This article reviews some of the new and unique procedures that use Botox as their primary modality. The procedures described are not meant as a replacement for surgical management, but to serve as an adjunct to surgery or to provide alternatives to patients who are unable or unwilling to undergo an operative procedure.

Pharmacologic browlift using botulinum toxin One of the most frequently treated areas of hyperkinetic facial wrinkles is the horizontal and vertical lines of the glabellar region. The muscles that are targeted are the corrugator and procerus, two of the primary depressors of the medial brow. It was observed that weakening of these muscles by either botulinum toxin injection during treatment of glabellar furrows or actual muscle lysis during browlift results in sometimes significant changes in brow elevation [8]. These observations led to the design of minimally invasive techniques to manipulate the position and shape of the brow. These techniques are based upon the principle that brow position is the result, at least partially, to the

* Corresponding author. The Maas Clinic, 2400 Clay Street, San Francisco, CA 94115. E-mail address: drmass@drmass.com (C.S. Maas).

1064-7406/03/$ see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S1064-7406(03)00092-0

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vector of force (Fig. 1) resultant from the equilibrium between brow depressors (orbicularis oculi, depressor supercilii, procerus, and corrugator muscles) and the primary brow elevator (the frontalis muscle) [9]. By selectively weakening the depressor musculature, the frontalis muscle acts unopposed and the resting brow position is elevated to a more superior position [9 12]. Endoscopic browlift relies on these identical principles, where lysis of the corrugator and procerus muscles permits a favorable vector equilibrium state for repositioning of the brow periosteum [13]. Similarly, several investigators proposed techniques to modify the contour and position of the brow by selective weakening of its elevator or depressor muscles using targeted botulinum toxin A injection. Frankel and Kamer [8] evaluated a technique for medial brow elevation. They injected 20 U of botulinum toxin A into the glabellar region of patients who had either glabellar rhytids or depressed medial brows. They found an elevation of the brow in 32% of patients at the medial canthus and 48% of the patients at the midpupillary line. Quantitative measurements were

Fig. 1. (A) Vectors of muscular pull in the brow region and injection sites (X) for lateral brow lifting. This is accomplished by weakening the depressor function of the orbicularis muscle which allows the lateral frontalis muscle to act unopposed. (B) Injection of botulinum toxin A into the lateral orbicularis muscle. (See also Color Plate 18.)

not displayed in this paper. Blinded observers found a subjective increase in brow elevation in 62% of patients. Although the results were not dramatic in this initial study, the concept of brow elevation without surgery was validated. Fagien [14] suggested that injection into the brow could be done in a creative fashion, finely adjusting brow position with selective elevation and depression of various brow locations. Isolated medial brow elevation or the surprised look is seen as a less desirable aesthetic outcome. Lateral or temporal brow elevation, conversely, is more consistent with the ideal eyebrow shape, where the highest point of the brow is located directly above the lateral limbus [15] or, as more recent data suggest, even closer to the lateral canthus [16]. This eyebrow shape is associated with a more natural and youthful appearance. Ahn et al [9] attempted to achieve temporal brow lifting by way of far more lateral injections than the previous study. They injected botulinum toxin A into the temporal orbital portion of the orbicularis oculi muscle. Twentytwo patients were treated with 7 to 10 units of botox to the superolateral portion of the muscle. Care was taken to ensure that all injections were administered superolateral to the orbital rim, to avoid diffusion of toxin through the orbital septum and into the orbit. Brow elevation was measured with calipers at the lateral brow and at the midpupillary line (Fig. 2). The degree of elevation was only an average of 1 mm at the midpupillary line, but was 4.8 mm at the lateral canthus (Fig. 3). Although results were modest and sometimes unpredictable, the investigators suggested that the technique may provide an alternative temporal browlift in patients who are reluctant or unable to undergo surgery. Others describe the usage of Botox injection into the brow region as an adjunctive to endoscopic browlift for the weakening of glabellar musculature. Huang et al [12] also looked at the ability of botulinum toxin A to achieve lifting of the brow. They combined medial and lateral injection techniques, using 10 units at the lateral orbital rim and 5 units at the corrugator medially. They measured elevation using digital photography 7 to 10 days postinjection. Their results showed maximal brow elevation in the central brow in relaxed and elevated positions. These investigators proposed that central brow elevation is the most aesthetically pleasing position. Complications reported in the studies of botulinum toxin A brow elevation were few, and included slight bruising, transient potashes, or brow depression. Although all of the studies showed substantial brow elevation in most subjects, results were unpredictable in many patients, and the study populations

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in the aesthetically pleasing female brow is fairly far lateral, almost over the lateral canthus [16]. Brow lifting and sculpting using botulinum toxin A can be accomplished. This technique is useful in a patient who is not a surgical candidate or who is not interested in surgical procedures. The complication rate is low, but the results remain unpredictable, and, in some case, subtle. Further studies with larger patient populations may be useful to determine ideal injection sites and dosages.

Rehabilitation of facial asymmetry using botulinum toxin The paralytic effects of botulinum Toxin A can be useful in the treatment of facial asymmetry that is a result of hyper- or hypofunctional problems. Botox was initially used to weaken hyperfunctional facial musculature that was caused by hereditary or postparalytic hemi-facial spasm [17 19]. Indications for this treatment were eventually expanded to include the management of aberrant facial nerve regeneration after facial paralysis. Aberrant regeneration of facial nerve fibers after facial palsy may lead to several unwanted effects, including involuntary synkinesis between the orbicularis oculi and orbicularis oris muscle (Fig. 4) or increased lacrimation of the affected eye,

Fig. 2. (A) Brow position before botulinum toxin A injection to the lateral orbicularis muscle. (B) Brow position 2 weeks after botulinum toxin A injection to the lateral orbicularis muscle. (See also Color Plate 19.)

were small (see references [8,9,12]). Each of the three studies described the site of ideal maximal brow elevation at a different location: medial [8], central [12], and lateral [9]. None of the studies addressed patient satisfaction, nor compared the various techniques. Recent data on the evaluation of 200 frontal photographs of fashion models and randomly selected individuals strongly suggested that the highest point

Fig. 3. Measurement of brow height using calipers at the lateral canthus. (See also Color Plate 20.)

Fig. 4. Patient partially recovered from left-sided facial paralysis smiling, demonstrating synkinesis of the orbicularis muscle and distorted smile caused by a pull from the contralateral perioral musculature. (See also Color Plate 21.)

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especially during salivation [20]. Several studies demonstrated that selective injection of Botox into the orbicularis oris can reduce the synkinetic phenomenon of involuntary eye closure with facial movement in most cases [20 23]. In addition, patients with injection into the lateral orbicularis muscle or with direct injection into the lacrimal gland had a reduction in hyperlacrimation [20]. Direct injection into the lacrimal gland seems to have a more potent effect. Side effects in treated patients were frequent; up to 6 out of 10 patients in one study had side effects that were fully reversible in all cases [20]. The most common complications included transient lid ptosis, lagopthalmos, or transient facial weakness. In addition, the investigators reported less frequent cases of transient diplopia and several episodes of conjunctivitis, symptoms of exposure keratopathy [20 23]. More recent studies focused on the usage of botox in the rehabilitation of patients wio had a unilateral hypofunctional facial asymmetry. Botox acts in this situation by weakening the contralateral musculature, to create a more balanced, harmonious appearance. Several studies showed an improvement in the asymmetry that was caused by facial nerve paralysis or

paresis. Clark and Berris [24] presented a case report where botulinum toxin was used to weaken a contralateral brow in a patient who had isolated postsurgical frontal branch weakness. They used 12 units of botulinum A toxin and found subjectively excellent improvement in asymmetry, which lasted for 2.5 months. The temporary, yet long-lasting, nature of this therapy is advantageous, because most traumatic, idiopathic, or postsurgical nerve injuries recover in a matter of months without requiring surgical reanimation [25]. Bikhazi and Maas [26] evaluated the ability of botox to not only weaken the contralateral facial musculature for its effects on facial balance, but for its effects in decreasing the distortion of the face by decreasing excessive pull from the nonparalyzed side during facial expression. This pull is particularly caused by the perioral facial musculature during expressions such as smiling (see Fig. 4). In their study, 10 patients received 10 to 25 units of botox that was injected into the zygomaticus major/minor muscles, levator labii superioris, risorius, or depressor anguli oris muscles. The site of muscular injection was determined by the location of maximal muscle pull. Eight of the 10 patients reported either moderate or marked improvement in their smiles. Complications

Fig. 5. (A) Platysmal banding before botulinum toxin A injection. (B) Platysmal banding 2 weeks after botulinum toxin A injection. (See also Color Plates 22 and 23.)

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were minimal, except for one patient who described a restriction of her normal smile that persisted for 2 months. The investigators noted that an advantage of this technique was that an injection could be targeted to specific locations and dosage could also be titrated over time to avoid complications.

Summary New indications for botulinum toxin A injection in facial plastic surgery have begun to emerge beyond the management of facial rhytids. This paper described a role for botulinum toxin in the rehabilitation from facial nerve paralysis, in the pharmacologic browlift, and in the nonsurgical management of platysmal bands. These procedures are not meant as a replacement for surgery, but rather as a less invasive alternative, or as an adjunctive modality. They are most useful in cases of functional or dynamic disorders, as opposed to problems of excessive or lax tissues. This article presented several clinical studies that give supportive evidence for the efficacy of the procedures. Further, larger studies with more objective measurements are necessary before these procedures become widely accepted.

Management of platysmal banding with botulinum toxin A The platysma muscle is a sheet of vertical muscular fibers that extend from the surface of the mandible to the upper chest. The primary role of the muscle is to tense the skin of the neck, but it also contributes to the appearance of aging in the neck. The anterior/medial fibers of the platysma muscle contribute to the process of the aging neck by gradual weakening and loss of connection with the fascia of deeper planes. The interdigitation between the platysma muscle fibers on either side is highly variable. The significant dehiscence that is found between the two sides in some patients results in the appearance of vertical platysmal bands in the neck upon muscular contraction [27]. The platysma may play a role in the horizontal lines of the neck through hyperkinetic activity and in jowling by depressing the skin and underlying soft tissue of the upper neck [6]. Several studies looked at the usage of botulinum toxin A in the management of platysmal bands. Matarasso et al [27] evaluated more than 1500 patients in several practices. High doses of botulinum toxin A, between 30 and 100 units depending on the degree of banding, were injected into each platysmal band at three to five sites per band. Patients were asked to grimace; neck bands were identified, grasped, and injected. They found the best results in patients who had mild to moderate banding, where 98.5% of patients had good to excellent results (Fig. 5). Detailed data analysis was not provided. Another group of investigators treated 26 patients with botulinum toxin A for their platysmal bands [28]. Smaller doses (5 to 20 units per band) were used, with subjective improvement in most cases. They noted that improvement was more noticeable during dynamic platysmal contraction than at rest. Significant complications, including dysphagia and neck weakness, have been reported as a result of the diffusion of the toxin into deeper neck musculature, especially during higher-dose injections [6,27]. These sequelae can be minimized by maintaining a superficial plane of injection. Other transient complications included edema, ecchymosis, and neck pain.

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