Botulinum toxin for cosmetic indications: Treatment of specific sites
- Alastair Carruthers, FRCPC
Alastair Carruthers, FRCPC
- Clinical Professor, Department of Dermatology and Skin Science
- University of British Columbia
- Jean Carruthers, MD, FRCSC
Jean Carruthers, MD, FRCSC
- Clinical Professor, Department of Ophthalmology and Visual Sciences
- University of British Columbia
Botulinum toxin is an injectable neuromodulator derived from neurotoxins produced by Clostridium botulinum, the bacterium responsible for botulism. As a result of the ability of the toxin to inhibit neurotransmission between peripheral nerves and muscle tissue, botulinum toxin is an effective treatment for aesthetic and medical concerns that are exacerbated by muscle contraction. Although US Food and Drug Administration (FDA) approval for the cosmetic use of onabotulinumtoxinA is limited to glabellar lines and lateral canthal lines (crow's feet) and FDA approval for incobotulinumtoxinA and abobotulinumtoxinA remains limited to the treatment of glabellar lines, injectable botulinum toxin is widely used for other cosmetic indications.
Examples of aesthetic concerns on the face and neck that can be improved with botulinum toxin will be reviewed here. The mechanism of action, available formulations, general use, and adverse effects of botulinum toxin in cosmetic settings are discussed separately. (See "Overview of botulinum toxin for cosmetic indications".)
The human face is composed of a complex array of muscles that act in concert to create facial expressions and fulfill vital functions. Clinicians with a thorough understanding of facial anatomy and the functional relationships between muscles in the face and neck can safely use botulinum toxin to selectively weaken specific muscles, resulting in favorable cosmetic results. An illustration of normal facial musculature is provided (figure 1).
Appropriate candidates for botulinum toxin injection are patients with specific cosmetic concerns that can be alleviated by local muscle weakening and who lack contraindications to therapy. Patients between the ages of 30 and 50 years often achieve the most benefit from treatment; a greater proportion of rhytides in older patients may be due to loss of skin elasticity, which is not alleviated by botulinum toxin [1,2]. (See "Overview of botulinum toxin for cosmetic indications", section on 'Contraindications'.)
Once patients have been determined to be good candidates for botulinum toxin therapy, care must be taken to ensure that the anatomic placement of injections is correct and that the doses used are appropriate based upon the treatment site and patient-specific characteristics (eg, anatomic variation, patient sex, and preferences regarding the magnitude of effect). Conservative treatment is preferred; improper placement of injections or an excessive dose of botulinum toxin can result in cosmetic or functional defects that persist for months.
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- GENERAL PRINCIPLES
- UPPER FACE
- Glabellar rhytides
- Horizontal forehead rhytides
- Lateral canthal rhytides (crow's feet)
- Brow lift
- Hypertrophic orbicularis oculi
- LOWER FACE
- Perioral lip rhytides
- Mouth frown and melomental folds
- Mental crease and peau d'orange chin
- Masseteric hypertrophy
- Gingival (gummy) smile
- Platysmal bands
- Horizontal neck lines
- OTHER SITES
- SUMMARY AND RECOMMENDATIONS