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.
- Ascher B, Rzany BJ, Grover R. Efficacy and safety of botulinum toxin type A in the treatment of lateral crow's feet: double-blind, placebo-controlled, dose-ranging study. Dermatol Surg 2009; 35:1478.
- Carruthers JA, Lowe NJ, Menter MA, et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 2002; 46:840.
- Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 1992; 18:17.
- Carruthers A, Carruthers J, Said S. Dose-ranging study of botulinum toxin type A in the treatment of glabellar rhytids in females. Dermatol Surg 2005; 31:414.
- Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg 2005; 31:1297.
- Carruthers JD, Glogau RG, Blitzer A, Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies--consensus recommendations. Plast Reconstr Surg 2008; 121:5S.
- Kane M, Donofrio L, Ascher B, et al. Expanding the use of neurotoxins in facial aesthetics: a consensus panel's assessment and recommendations. J Drugs Dermatol 2010; 9:s7.
- Carruthers A, Carruthers J, Cohen J. A prospective, double-blind, randomized, parallel- group, dose-ranging study of botulinum toxin type a in female subjects with horizontal forehead rhytides. Dermatol Surg 2003; 29:461.
- Lowe NJ, Ascher B, Heckmann M, et al. Double-blind, randomized, placebo-controlled, dose-response study of the safety and efficacy of botulinum toxin type A in subjects with crow's feet. Dermatol Surg 2005; 31:257.
- Prager W, Wissmüller E, Kollhorst B, et al. Comparison of two botulinum toxin type A preparations for treating crow's feet: a split-face, double-blind, proof-of-concept study. Dermatol Surg 2010; 36 Suppl 4:2155.
- Lowe NJ, Lask G, Yamauchi P, Moore D. Bilateral, double-blind, randomized comparison of 3 doses of botulinum toxin type A and placebo in patients with crow's feet. J Am Acad Dermatol 2002; 47:834.
- http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm367662.htm (Accessed on September 12, 2013).
- Frankel AS, Kamer FM. Chemical browlift. Arch Otolaryngol Head Neck Surg 1998; 124:321.
- Huilgol SC, Carruthers A, Carruthers JD. Raising eyebrows with botulinum toxin. Dermatol Surg 1999; 25:373.
- Carruthers A, Carruthers J. Eyebrow height after botulinum toxin type A to the glabella. Dermatol Surg 2007; 33:S26.
- Maas CS, Kim EJ. Temporal brow lift using botulinum toxin A: an update. Plast Reconstr Surg 2003; 112:109S.
- Ahn MS, Catten M, Maas CS. Temporal brow lift using botulinum toxin A. Plast Reconstr Surg 2000; 105:1129.
- Flynn TC, Carruthers JA, Carruthers JA. Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye. Dermatol Surg 2001; 27:703.
- Flynn TC, Carruthers JA, Carruthers JA, Clark RE 2nd. Botulinum A toxin (BOTOX) in the lower eyelid: dose-finding study. Dermatol Surg 2003; 29:943.
- Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg 2003; 29:468.
- Carruthers J, Carruthers A. BOTOX use in the mid and lower face and neck. Semin Cutan Med Surg 2001; 20:85.
- Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: adjunctive use in facial aesthetic surgery. Plast Reconstr Surg 1999; 103:701.
- Fagien S. Botulinum toxin type A for facial aesthetic enhancement: role in facial shaping. Plast Reconstr Surg 2003; 112:6S.
- Semchyshyn N, Sengelmann RD. Botulinum toxin A treatment of perioral rhytides. Dermatol Surg 2003; 29:490.
- Carruthers A, Carruthers J, Monheit GD, et al. Multicenter, randomized, parallel-group study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation. Dermatol Surg 2010; 36 Suppl 4:2121.
- Carruthers J, Carruthers A, Monheit GD, Davis PG. Multicenter, randomized, parallel-group study of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation: satisfaction and patient-reported outcomes. Dermatol Surg 2010; 36 Suppl 4:2135.
- Custis T, Beynet D, Carranza D, et al. Comparison of treatment of melomental fold rhytides with cross-linked hyaluronic acid combined with onabotulinumtoxina and cross-linked hyaluronic acid alone. Dermatol Surg 2010; 36 Suppl 3:1852.
- Yu CC, Chen PK, Chen YR. Botulinum toxin a for lower facial contouring: a prospective study. Aesthetic Plast Surg 2007; 31:445.
- Baş B, Ozan B, Muğlali M, Celebi N. Treatment of masseteric hypertrophy with botulinum toxin: a report of two cases. Med Oral Patol Oral Cir Bucal 2010; 15:e649.
- Al-Muharraqi MA, Fedorowicz Z, Al Bareeq J, et al. Botulinum toxin for masseter hypertrophy. Cochrane Database Syst Rev 2009; :CD007510.
- Fedorowicz Z, van Zuuren EJ, Schoones J. Botulinum toxin for masseter hypertrophy. Cochrane Database Syst Rev 2013; :CD007510.
- To EW, Ahuja AT, Ho WS, et al. A prospective study of the effect of botulinum toxin A on masseteric muscle hypertrophy with ultrasonographic and electromyographic measurement. Br J Plast Surg 2001; 54:197.
- von Lindern JJ, Niederhagen B, Appel T, et al. Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscles: an alternative treatment. Plast Reconstr Surg 2001; 107:327.
- Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of the lower face. Dermatol Surg 2003; 29:477.
- Liew S, Dart A. Nonsurgical reshaping of the lower face. Aesthet Surg J 2008; 28:251.
- Chikhani L, Dichamp J. [Bruxism, temporo-mandibular dysfunction and botulinum toxin]. Ann Readapt Med Phys 2003; 46:333.
- Kim NH, Park RH, Park JB. Botulinum toxin type A for the treatment of hypertrophy of the masseter muscle. Plast Reconstr Surg 2010; 125:1693.
- Kim KS, Byun YS, Kim YJ, Kim ST. Muscle weakness after repeated injection of botulinum toxin type A evaluated according to bite force measurement of human masseter muscle. Dermatol Surg 2009; 35:1902.
- Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol 2010; 63:1042.
- Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am J Orthod Dentofacial Orthop 2008; 133:195.
- Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop 2005; 127:214.
- Matarasso A, Matarasso SL, Brandt FS, Bellman B. Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg 1999; 103:645.
- Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg 1999; 103:656.
- Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol Surg 1998; 24:1232.
- Brandt FS, Boker A. Botulinum toxin for the treatment of neck lines and neck bands. Dermatol Clin 2004; 22:159.
- Carruthers J, Carruthers A. Botulinum toxin A in the mid and lower face and neck. Dermatol Clin 2004; 22:151.
- Carruthers J, Carruthers A. Practical cosmetic Botox techniques. J Cutan Med Surg 1999; 3 Suppl 4:S49.
- Jeong SY, Park KY, Seok J, et al. Botulinum toxin injection for contouring shoulder. J Eur Acad Dermatol Venereol 2017; 31:e46.
- 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