Introduction to Esthetic Medicine

The world of esthetic medicine and cosmetic surgery are encompassing new and emerging medical technologies for skin care and the treatment of various skin conditions. The effects of the sun leads to skin damage, the acceleration of skin aging, and the appearance of skin disease states. Once a person’s skin id type is determined, they may be amenable to skin aging treatments and skin aging products. Botox injections are used for wrinkled skin. They can improve the appearance of forehead wrinkles, frown lines, Crow’s feet, laugh lines, and lip stick lines.

Beauty and youth is associated with fullness of facial features. Gradual loss of tissue with aging leads to hollowed out areas in the face and thinning lips. As skin looses its elasticity, it can sag, deepening folds in the face. Injectable fillers such as Cosmoderm (collagen), Restylane, Juvederm, Radiesse, and silicone can be used for lip augmentation and to soften the nasolabial folds or smile lines.

With sun damage and aging, wrinkling, skin pigmentation problems, and abnormal blood vessels appear. Wrinkle creams have limited effectiveness. To treat these conditions, lasers have broad applications including laser skin resurfacing or rejuvenation, laser vein removal, treatment of acne scarring, and skin tightening treatments. Intense pulse light is another therapy that can be used for photofacial treatments, skin rejuvenation, and treating vascular lesions like spider veins and rosacea. It can also treat pigmented skin lesions like brown spots, age spots, sun spots, and melasma. Other skin resurfacing techniques include microdermabrasion and chemical peels. Light based technologies are also used for laser hair removal for unwanted facial hair and hair from other areas as well. Lasers are also a form of acne treatment and an alternative to the use of acne medication.

There are several therapies for treating varicose veins and spider veins specifically including sclerotherapy treatment of varicose veins, endovenous laser therapy (EVLT), and ambulatory phlebectomy (vein stripping).

Finally, as America’s body fat index rises, liposuction, cellulite treatments, and body sculpting techniques are becoming more popular.

This web site is meant to be a little more in information source for those interested in cosmetic medicine.

The Treatment of Acne

The Treatment of Acne

Acne is a skin condition that can present as small lumps, nodules, redness, or cysts. It affects most teenagers but can affect adults too. Some cases can result in permanent scarring. Lesions can occur on the face, neck, chest, back, and arms.

Acne is a disease of the sebaceous gland. These are glands in the skin that produce an oily substance called sebum. They are connected to hair follicles. When these glands become plugged, they become growing collections of sebum, dead cells, hairs, and bacteria.

Acne can present in several ways, as comedones, nodules, and cysts. A comedo is a plugged sebaceous follicle. When the opening to the plugged follicle is wide, it is called a blackhead because the follicular plug appears black. A white head is seen when the opening to the follicle is narrow and looks like a skin colored bump on the skin.

Comedones

A papule is a small (<5mm) solid lump that protrudes above the skin's surface.

Papules

A pustule is a rounded lump in the skin containing pus, a mixture of white blood cells, dead skin cells, and bacteria. If they heal without progressing to cystic forms, they usually do not result in scarring.

Pustules, papules, comedones

A macule is a temporary red spot left where an acne lesion has healed. It is red and flat, and may persist for days to weeks. These lesions, when numerous, can coalesce and give a red inflamed face appearance.

Reddish appearance of macules

A nodule is a solid lump that goes deeper into the skin and can lead to scarring. Nodules can become painful. Nodular acne is a severe form of acne that may be resistant to most treatments.

A cyst is a sac containing pus but it is larger than a pustule. It can be very inflamed, go deeper into the skin and cause scarring. Cysts and nodules occurring together is a severe form of acne called nodulocystic disease.

Nodulocystic disease

Acne occurs in almost all people between the ages of 12-17. Up to 40% of mid teenagers have acne severe enough to merit treatment by a doctor. Acne usually starts by the age of 10 or 13 and lasts for 5-10 years. It usually resolves in the twenties but can persist into adulthood. Some people can get acne for the first time as adults. It affects men and women equally, but men tend to have more severe forms. Women may have intermittent acne related to menstral cycles and acne caused by cosmetics.

Acne scarring

The inflammation that occurs around a plugged sebaceous gland can heal leaving scars. Some people are more prone to scarring than others. Scarring occurs frequently from nodulocystic acne, but may occur with less severe forms as well.

Scars from nodulocystic disease

It is difficult to predict precisely who will get scarring, how bad scars will get, or how long they will last. But scarring may be prevented by treating acne as early as possible and as long as necessary. The better the control of inflammation the less likely scarring will result.

There are two kinds of scarring, scars with overgrowth of tissue and scars with loss of tissue. Tissue overgrowth results in hypertrophic scars or keloids. An excess amount of scar tissue or collagen is built up to form raised irregularly shaped masses. They can be 1-2 mm in diameter or over 1 cm wide and can persist for years. They may run in families.

Hypertrophic scarring or keloids

Scars associated with tissue loss are similar to scars from chicken pox and are more common. They can be ice pick type scars or wide deep depressions. They can be skin colored or whitish.

Scarring can be treated and improved. Collagen like substances like Restylane or Juvederm can be injected under the scars to fill in depressed scars. It does not work for ice pick or keloid scars. The benefits may last for 6 months. Laser therapies can be used to shave down raised scars or pare down the edges of depressed scars to make them shallower and promote healing over of depressed scars. Narrow scars like ice pick scars can be “punch” excised. Keloids sometimes can be removed, injected with steroids, or retinoic acid applied to the skin.

Acne can have significant social impact as well. It has been associated with social withdrawal, decreased self esteem, poor body image, and depression.

Treatment of Acne

Mild Acne

Mild acne presents as blackheads, whiteheads, or pustules. It can be controlled with gentle washing of the areas with warm water and mild soap two times a day to remove excess oil and dead skin. Over the counter acne creams like benzoyl peroxide or salicylic acid are used. Acne lesions should not be popped, picked, or squeezed. This can result in spread of inflammation or super infection with other bacteria making inflammation worse. Acne can lead to more irritation and make acne worse. The cosmetic or toiletries used should be labeled as noncomedogenic, does not clog pores. One can avoid aggravating acne by keeping oily hair off the face and washing it daily. Avoiding oily hair care products, and wearing cotton or moleskin under sports equipment to keep them off the skin can help. Tanning may mask acne but does not clear acne. It does increase risk of skin cancer and may react with some skin ointments like Retin A making skin more prone to light injury.

Home treatment requires 4-8 weeks to see improvement. And once acne clears, treatment must continue to keep new lesions from forming. Combination therapy with topical (ointments or creams) antibiotics and topical retinoids are commonly used.

Heavy foundation make up should not be used. Powder blushes and eye shadow is preferred over creams. Green undercover cosmetics help mask red acne lesions. Studies have not proven that stress or diet promote acne, but many people feel chocolate, colas, peanuts, shellfish, and fatty foods worsen acne.

Moderate to moderately sever acne

In moderate to moderately severe acne, there are several whiteheads, blackheads, papules, and pustules covering ¼ to ¾ of the face and other areas. Treatment includes comedo extraction or laser/light therapies in addition to over the counter medications. Perscription medications are used as topical antibiotics, topical retinoids, oral antibiotics or oral contraceptives. Treatment should be early to help prevent scarring.

Severe Acne

Severe acne present with deep nodules, cysts, inflammation, tissue damage, and scarring. It requires aggressive treatment by a dermatologist. Methods include drainage of lesions, surgical incision, interlesional steroid injections, isoretinoin (Accutane), oral antibiotics, and oral contraceptives.

Acne surgery are extractions done under sterile conditions by trained professionals. Intralesional steroid injections are for severely inflamed acne cysts that will likely rupture and scar. Cysts can be injected with diluted steroids to decrease inflammation and allow healing over a period of 3-5 days. Isotretinoin is a potent synthetic drug reserved for severe cystic or resistant acne. It is a pill taken 1-2 times per day for 16-20 weeks. It works on excess oil production, clogged pores, P. acnes bacteria and inflammation. Remissions last months to years. Many patients only need one course of therapy. Isotretinoin has several serious side effects including birth defects. Women cannot get pregnant on this drug. Women are required to get 2 pregnancy tests and use 2 forms of contraception 1 month before therapy and for 1 month after therapy. They cannot breast feed during this time. Other side effects include chest or abdominal pain, trouble swallowing, headaches, joint pain, nausea, vomiting, diarrhea, bleeding, depression, dryness of skin eyes or nose, and hair thinning. Patients are monitored with monthly blood tests for chemical abnormalities. Medication must be taken as ordered even after acne clears to prevent recurrence. Reddish macules may replace acne lesions but these fade in 6-8 weeks.

Oral antibiotics reduce P. acnes bacteria and decreases inflammation. Doxycycline, erythromycin minocycline and tetracycline have been used. Resistance to antibiotics can occur.

Oral contraceptives suppress overactive sebaceous glands and can be used as long term therapy. It cannot be used in women who smoke, have blood clotting disorders, are older than 35, or have migraine headaches without the advice of a gynecologist. Spironolactone is a steroid sometimes used with oral contraceptives to decrease androgen (male hormone) production in females. Side effects include irregular periods, breast tenderness, headache and fatigue.

Over the counter medicines

Alcohol and acetone used together is a degreasing agent and antibacterial. Benzoyl peroxide reduces P. acnes and removes dead skin to prevent comedones. The main side effect is skin dryness. It can bleach hair, sheets , and clothing. It should be continued after acne clears to prevent recurrences.

Salicylic acid helps decrease abnormal shedding of skin cells and unclogs pores. It does not have any effect on sebum production or P. acnes bacteria. It must be used continuously to prevent outbreaks. It is in many over the counter preparations. It can be irritating to the skin. Other agents like sulfur and resourcinol may be in over the counter products.

Physical procedures

Chemical peels

Light chemical peels with glycolic acid can loosen blackheads and decrease papules. It peels the top layer of skin and opens plugged follicles. Comedo extractions can be done with sterile devices by professionals. Large cysts can be drained by trained medical personnel. Laser and light therapies can treat P. acnes without the bother of taking medications and can treat hard to reach areas like the back.

Prescription Medications

Topical antibiotics

Azelaic acid treats mild to moderate acne by decreasing P. acne bacteria, abnormal skin cell shedding and inflammation. It can treat dark spots that occur in acne patients of color. It can be used for years but may cause skin dryness and lightening.

Benzoyl peroxide kills P, acnes bacteria and is anti-inflammatory. It can increase effectiveness of antibiotics and used in combination can help prevent resistance.

Clindamycin is a topical antibiotic that decreases P. acnes bacteria and inflammation. It is well tolerated but can cause skin dryness and irritation. Erythromycin is a topical antibiotic active against P. acnes bacteria and is anti-inflammatory. It too can cause skin dryness and irritation. Sodium sulfacetamide is a topical antibiotic that treats P acnes bacteria and opens clogged pores in inflammatory acne. Some patients do not like the sulfur odor.

Topical Retinoids

This is a derivative of vitamin A that treats mild to moderately severe acne. They unclog pores. They may diminish wrinkles. They can irritate the skin and increase sensitivity to the sun.

Adapalene is a gel or cream that unclogs pores and is anti-inflammatory. Improvement can be seen in 8-12 weeks. Side effects include skin irritation and dryness.

Tazarotene is a gel or cream that keeps skin pores clear. It can cause birth defects and skin irritation.

Tretinoin unclogs pores and keeps them unclogged. It can be irritating causing redness, scaling, itching, dryness, and burning.

Oral antibiotics

These are for moderate to severe acne to treat P. acnes bacteria. Treatment begins with higher doses and then decreased as acne improves. Duration of therapy is 6 months or less. Erythromycin, tetracycline, doxycycline, and minocycline are used.

Laser Therapy

Blue light therapy has been approved by the FDA. It kills P. acnes bacteria in inflammatory acne resistant to other therapies. It does not contain UV light which can damage skin and is not used for acne treatment anymore. Usually 8, 15 minute sessions are done over 4 weeks. Studies demonstrate many but not all patients can see up to 55% clearance. Side effects include skin color change, swelling and dryness. It may not be useful for nodulocystic acne.

Intense pulsed light therapy destroys P. acnes bacteria and decreases sebum production by shrinking sebaceous glands. It is FDA approved to treat mild to moderate acne. Side effects may include changes in skin coloration and must be avoided or used carefully in darker skin types. For these people, laser therapy with a 1319 nm wave length can be used instead of or in combination with IPL.

ALA and light therapy

A solution of 5-aminolevulunic acid (ALA) is placed on the skin for 15-60 minutes. It concentrates in the sebaceous glands and is converted by light therapy to a chemical toxic to sebaceous glands and bacteria to reduce acne. Blue light or IPL can be used.

Other topical treatments

Ziana gel is a topical treatment for acne vulgaris in patients 12 years or older. It contains clindamycin phosphate 1.2% and tretinoin 0.025% in 2, 30, and 60 gm tubes. At bedtime, wash the face with mild soap and warm water, then a pea sized amount is squeezed onto the finger tip and dotted on the chin, cheeks, nose, and forehead, then gently rubbed over the entire face. It should be kept away from the eyes, mouth, angles of the nose and mucous membranes. A sunscreen should be applied every morning and reapplied during the day as needed. Patients should avoid exposure to sunlight, UV light and sunlamps. Ziana may cause skin redness, scaling, itching, burning, or stinging. It may lead to diarrhea or abdominal cramps from severe colitis associated with Clostridium difficile infection.

Retin A (tretinoin) cream 0.05% (0.1 – 0.04%) is a metabolite of vitamin A for the treatment of acne vulgaris where comedones, papules, and pustules predominate. It is not recommended as sole therapy for severe pustular deep nodulocystic acne. It should be applied once a day or at bedtime lightly covering the entire affected area. During early weeks of therapy, inflammatory lesions may worsen before they improve and is not a reason to stop the medicine. Results should be noticed after 2-3 weeks, but 6 weeks may be needed to see definite improvement. Once lesions respond it may be possible to decrease frequency of applications. Exposure to sunlight and sunlamps should be minimized. Sunburn patients should avoid use until the burn clears. Sunscreen of at least SPF 15 should be used. Extremes of wind or cold can be irritating. Soaps and cosmetics with strong drying effects or high alcohol content should be used with caution. It should be kept out of eyes, mouth angles of the nose and mucous membranes. Studies do not show harm to the fetus in animals. It is not known if there is excretion in breast milk so caution should be exercised. Side effects include redness, peeling, blistering, and crusting. True contact allergies are rare.

Cleocin T topical gel or lotion comes in pleget applicators that are used twice a day with 30-60 cc applicator bottles or a carton of 60 single use pledgets. The gel comes in 30 or 60 gm tubes. Side effects include burning, itching, drying, redness, peeling, and colitis. Contact to eyes, nose mouth, and broken skin should be avoided. It may take 2-6 weeks to note improvement and up to 12 weeks to see full benefit.

Accutane (isotretinoin) is a vitamin A analog approved for treating severe nodular acne resistant to other treatments. Severe nodular acne is defined by many red swollen tender lumps pea sized or larger. Nodular acne can cause permanent scarring if untreated. Women who can get pregnant follow a specific program of testing and birth control. Accutane is given twice a day with meals. For severe acne, 35-38% are cured after one course of treatment and 70% experience long term remission. Adult women have higher relapse rates than teenagers. One course of therapy lasts 4-6 months. The dose is 0.5-1 mg/kg body weight. The total dose taken should not be less than 120 mg/kg over the entire treatment period. Oily skin, giant blackheads, younger teen, acne on chest or back have higher relapse rates. Multiple courses can be taken.

Accutane affects sebaceous glands to produce normal amounts and composition of oils to prevent pores from clogging. It prevents excess keratin production decreasing comedone formation. Side effects include blurred vision, depression, stomach or chest pain, diarrhea, headache, nausea, muscle pain, increased cholesterol, and birth defects. Periodic blood tests are required.

Oral antibiotics

Oral antibiotics are for moderate to severe acne vulgaris. Moderate inflammatory acne is treated with oral antibiotics and topical reinoids with benzoyl peroxide. Mild acne is treated with topical antibiotics or benzoyl peroxide with a retinoid. The initial benefits may take 1-2 months. It is necessary to be compliant for 8-12 weeks to see if it is working. Doxycycline 100 mg bid is taken for the first few weeks then the dose is decreased to once a day for 1-3 months. The goal is to stop the antibiotic by the end of the third month. Doxycycline comes in two forms, hyclate and monohydrate. The hyclate is associated with more GI side effects. GI side effects are minimized by taking the medication 30 minutes after a meal. Photosensitivity may occur with doxycycline so avoid tanning beds. Minocycline can cause hypersensitivity reactions, lupus, dizziness, vertigo, pigmentation changes, and bluish discoloration.

Botox Therapy: Introduction

Botox Cosmetic Treatment of the Neck and Face

Introduction

Medical technology has spawned new therapies to treat the aging face. Botox, injectable fillers (like collagen and Restylane), and laser light therapies have been developed to treat wrinkles and folds. These lines form as the underlying muscles in the face contract over and over again. Eventually, the folds in the skin become permanent. These are most commonly seen on the forehead, between the eyebrows, around the eyes, around the mouth and as a line running from the nose to the corner of the mouth (the nasolaabial fold). Sunlight and smoking worsen these changes. Too much sun is the biggest factor. Botox is a chemical injected into the muscle to stop underlying muscle movement and will soften these lines.

As the skin ages, it becomes less elastic and begins to sag. Fat is lost and the roundness of the face in the young is replaced with a more sunken look. The bones wear down adding to the loss of facial fullness. The cartilage can stretch out causing the nose to droop. These signs of aging are more difficult to treat but can be addressed with injectable fillers and plastic surgery.

There is a scale called the Glogau Photoaging classification that describes the events of facial aging. In Class I, there is minimal wrinkling. People are in their 20’s or 30’s and wear little or no make up. In the type II, discolored skin lesions occur and smile lines appear around the mouth. People are in their late 30 to 40’s and wear some foundation make up. In class III, there is more discoloration and wrinkles present even without facial movement. People are in their 50’s or older and always wear heavy foundation. In type IV, the skin may be yellow-gray, wrinkles are widespread, and skin cancers may occur. These people are in their 60’s or 70’s and cannot wear make up because it cakes up and cracks.

When planning treatment, the face is divided into thirds. The upper third goes from the top of the forehead to the glabella (the area between the eyebrows). The middle third goes from the glabella to below the nose. The lower third goes from below the nose to the chin.

The face divided into thirds

In the upper third of the face, the forehead is damaged by sun exposure. Because of this and contraction of the forehead muscles, long horizontal lines appear. There are muscles that run from the root of the nose to the brow. When they contract they cause squinch lines. The tissue there can also sag and make these lines worse. Botox can halt this muscle movement to treat these lines.

Squinch lines, Forehead lines, Brow lines

The appearance of the eye and eyebrows can be changed as well. The perfect eyebrow in females is club shaped on the inside and gradually tapers toward the outside end. It has a gull wing shape with the outside end higher than the inside end. In males, the eyebrow is just above or at the bony rim above the eye and it runs horizontally. The brow can droop giving a fatigued appearance or drop so low as to get in the way of vision. Crow’s feet are fine wrinkles that fan out from the corner of the eye. Sun damage, loss of fat and skin loosening cause changes around the eyes, cheeks, and nose.


The ideal female brow The ideal male brow

Crow’s feet

In the lower third of the face the lips, chin, cheek, and neck are affected. Wrinkles fan out around the mouth. The mouth corners droop giving a saddened look. The lip border thins and the lip flattens and looses fullness. Botox is used fro addressing wrinkles caused by contraction of facial muscles. People can see this best looking in a mirror and performing various movements to see the wrinkles form and what happens to them when the muscle rests. For example, lip lines form when the lips are pursed with speaking. More lines form around the mouth when smiling.

Marionette or drool lines

The use of Botox bowever, carries some risks. If someone has a drooping eyebrow, the forehead muscle may be used to lift the brow to see. If Botox is used to paralyze the forehead muscle to treat forehead wrinkles, the brow may drop further and interfere with vision. Also, if too much Botox is used around the mouth to treat the vertical wrinkles spreading up from the lip, eating and speaking could be affected.

Botox Therapy: How It Works

How Botox Works

Botulinum toxin causes food poisoning and was developed at one time for biologic warfare. Now it is medical treatment for wrinkles, excessive sweating of the palms and armpits, and for headaches. Botulinum toxin food poisoning caused blurred vision, nausea, and fatal paralysis. It was found in salty food like sausage. Botulis is the Greek word for sausage. Clostridium botulinum is the bacteria that makes the toxin. There is a type A, B, and E. Type A is most used for medical purposes. Dr. Herman Sommer developed the toxin in 1920. Medical use began in the 1950’s by Dr. Vernon brooks and Dr. Alan Scott. Dr. Jean Carruthers is credited with discovering the cosmetic use of the toxin in 1987. While treating muscle spasms around the eye she found that the wrinkles between the eyebrows improved. The FDA later approved the use of Botox A and it has been used in cosmetic procedures since 1997.

Most wrinkles form as folds in the skin when the underlying muscles contract. As skin ages it does not recover as well and the folds persist at rest. Botox is injected into these muscles to paralyze them to some extent and flatten out the lines. Botox works at the neuromuscular junction where the nerve contacts the muscle it stimulates to move. At this junction a chemical called acetylcholine is released from the nerve ending into the muscle to stimulate it. Botox prevents the release of acetylcholine so the muscles cannot be triggered to move. The muscle weakness starts in 2-4 days and is maximal at 7-10 days. The muscle recovers from the effects of Botox in 2-5 months and the wrinkles come back. However, with repeated treatments, the improvement can last longer, up to a year on occasion and with wrinkles that are not as deep. When the area rests more fibrous tissue can form at the bottom of the wrinkle to give a more permanent effect as well.

The neuromuscular junction where nerve ending meets muscle

Acetylcholine release at the neuromuscular junction, Botox stops this release

Botox comes in 100 unit vials and is usually diluted before injecting it. It is prepared by mixing it with pure saline. It can also be mixed with saline preserved with benzylchloride which may help decrease the pain of injection. The company recommends using the prepared dose with in 4 hours and handling Botox gently. However studies do not show a clear difference in effectiveness when it is shaken or injected up to 6 weeks after the dose is mixed. There are other preparations like Mybloc (Botox type B) which is weaker and requires about 50-150 times a Botox A dose to be effective. Reloxin is another brand of Botox A but needs 2.5-3 times the amount of conventional Botox. Puretox is another type A toxin being studied.

The way Botox is diluted can affect the treatment. With more dilution, a larger volume of drug is injected. The drug can spread out more and cover more areas with fewer injections. However, you risk it going into other unwanted areas and causing more side effects perhaps interfering with speaking or vision. Resistance because of antibody formation is very rare. Botox can be used in combination with other treatments like injectable fillers and lasers to make the improvements last longer. Botox can be given before a laser is used to remove the outer layer of the skin, a resurfacing procedure. So as the skin heals over, the area is kept still so the wrinkles do not reform. Botox is the most popular cosmetic treatment in America with over 3 million people treated in 2005.

Botox Therapy: Anatomy of the Face

Facial Anatomy

The Upper Third of the Face
The eyebrow is an important part of facial appearance. In females, it should curve above the bony rim over the eye about ½ inch with the highest point over the outside corner of the eye. In males, the brow is at the bony rim above the eye and is more flat in shape. With age the brows droop. Botox can dramatically change the eyebrow position bringing either end up or down making one look happy, sad, or crazed.

The frontalis muscle is under the forehead and raises the brow.

The muscles of the upper third of the face

Double bellied frontalis muscle, Single bellied frontalis muscle

There are four muscles that pull the brow down, the procerus, the corrugator supercilii, the depressor supercilii, and the orbicularis oculi. The corrugator pulls the eyebrow in and down. Activity of this muscle creates vertical or angled lines between the eyes.

The corrugator muscle

The procerus is a narrow muscle that goes from the root of the nose up to the mid forehead. It causes horizontal wrinkles over the bridge of the nose. The depressor supercilii runs above the inside corners of the eye.

The procerus muscle The depressor supercilii muscle

The orbicularis oculi encircles the eye. It pulls the brow in and down causing a vertical fold in the middle of the brow especially in squinters. On the outside corner of the eye it causes Crow’s feet. Below the eye it helps raise the cheek.


Treatment of this muscle can be difficult. Misplaced drug can cause the upper eyelid to sag interfering with vision. It can make lower face wrinkles worse by allowing the cheek to droop. Also if Botox is injected into the lower eyelid, it can droop, opening the eye too much, and leaving the patient with the inability to close the eye. Therefore, the muscle tone of the lower lid must be tested with a snap test before injection. Also if the muscle under the eye is weakened too much, the underlying tissue can push out and create a swollen tired look.

The orbicularis oculi muscle and Crow’s
feet

The Midface Anatomy

The muscles of the mid and lower face

Treatments here affect wrinkles and folds around the mouth and asymmetry of the face. The levator labi superioris is a narrow muscle that runs along the side of the nose and connects to the corner of the mouth. It is a major cause of the nasolabial fold that runs from the nostril to the corner of the mouth. It helps raise the lip. Contraction of one side causes a sneer, while contraction of both sides creates bunny lines (angled folds along the side of the nose). A Botox injection just outside of the nostril can soften the nasolabial fold. It can decrease the elevation of the upper lip during a smile, so it is best for people with a gummy smile.

The Lower Third of the Face and Neck

The muscles of the lower face


Contraction of the depressor anguli oris muscle

Treatment can raise the corner of the mouth, smooth out pits in the chin and help hide neck bands. The orbicularis oris muscle surrounds the mouth. It is needed to speak and chew, push out the lips, pull the lips back, and move the corners of the mouth. Botox can treat the vertical wrinkles on the upper and lower lips, but too much can cause problems with the functions of the mouth. The depressor anguli oris runs from the jaw to the corner of the mouth. It pulls the mouth corner down. Botox injected into this muscle raises the mouth corner. The injections must avoid the depressor labii inferioris to avoid problems with eating and speaking and a disfigured smile.

Peach pit chin

The mentalis muscle creates a pitted texture of the skin over the chin. Botox will smooth this effect out.

The different distributions of the platysmal muscle

Neck bands

The platysma is a wide flat muscle that runs from the chest and collarbone up to the jaw and corners of the mouth. Sometimes bands form and stick out from the neck like ropes (Turkey neck). Botox can effectively treat these bands. Too much Botox can result in serious complications including difficulty swallowing, choking, and voice changes.

Botox Therapy: Treatment of the Upper Face

Treatment of the Upper Face

Patients must be selected carefully for cosmetic Botox treatment. They must be well educated about the benefits, risks, and limitations to the procedure. Patients with deep folds, severe age spots, spider veins and poor skin texture will not get great improvement with Botox treatment alone. They should realize that the treatments will need to be repeated every 3-6 months to sustain the effect. People with unrealistic expectations will not be satisfied.

Treatment of the upper face includes horizontal forehead wrinkles, Crow’s feet, and lines between the eyebrows.

General procedure
Before treatment, photographs should be taken as a part of before and after shots, with the muscles fully contracting and at rest. Various movements should be done including smiling and frowning. The skin lines are marked with a soft eyeliner pencil. Botox is drawn up into a syringe with a very fine silicon coated needle that minimizes the pain with injections. Anesthesia is not needed but can be used. Pressing ice onto the area to be injected may help. Failing that, an anesthetic cream can be applied about 30 minutes before injection. Injections should be into the muscle. Injecting into the skin will be less effective. Multiple injections are often necessary to make sure the drug is dispersed thoughout the muscle being targeted.

Glabellar Frown Lines (wrinkles between the eyebrows)
Males have more muscle in the brow compared to females. Therefore, they will need 60-80 units of Botox, while females may need 30-40 units total. If this is not effective then the doses can be increased to 50 and 100 units for women and men respectively. The subject should be seated chin down, and below the operator. The first injection is just above the eyebrow directly above the inner corner of the eye. 4-6 units are given, then the needle is advanced upward and 4-5 more units are given. The opposite side is done the same way. Then 5-10 units are injected right between the eyes to get the procerus muscle. Another injection can be done above the eyebrow about ½ inch directly above the middle of the eye. The patients should stay upright for 2-3 hours. They should frown a lot but not push on the treatment area. A follow up appointment should be in 2-3 weeks and touch up injections can be done. Botox treatments can be repeated every 3-4 months for a year. Sometimes the improvement may last 6-8 months however.


Treating the glabellar frown lines Injection sites for treating the glabella

Before and after injections for glabellar frown lines

Horizontal Forehead Lines
Injecting the forehead for wrinkles usually lasts 4-6 months. However, over treatment can cause lowering of the brow resulting in an angry expression. Keeping injection sites well above the brow and using conservative dosing will help avoid complications. In females 48 units are used, ½ the dose into the frontalis muscle and the other half into the brow depressor muscles.

Injection sites for forehead lines

Before and after forehead injections Before and after forehead injections

Prominent Orbicularis Oculi Muscle
Contraction of parts of the orbicularis oculi muscle during a smile will decrease the eye lid opening. If the muscle is too bulky, the eye may appear swollen. A well placed injection just below the eye can help. The dose is limited to 2-4 units to avoid the dry eye side effect. This therapy works well for patients with a good snap test result. When the eyelid is pulled off the eye, it snaps back quickly when released. This is the normal response. If the lid movement is sluggish, then Botox may lead to drooping of the lower lid and inability to close the eye.

Injections site for treatment of the orbicularis oculi muscle

Combination Treatment
Botox can be used for the fine wrinkles and injectable fillers like collagen or Restylane can be used to fill in the deeper folds. Botox is usually given about a week before the filler to keep the area still and get a better result with the filler implant. Botox can be given with plastic surgery to prevent recurrence of wrinkling. It is also used before laser resurfacing procedures where laser burns can heal over without the skin folding over trying to create a new wrinkle.

Complications
Short term side effects include bruising and swelling at the injection site, headaches, and flu like symptoms. There is a less than a 1% chance of eye lid or eyebrow drooping. This could result in the eyebrows appearing asymmetric or give an angry expression. To avoid this several things can be done. Patients with baseline brow sagging should not be treated. Injections of the brow depressor muscles should be done first before injecting the frontalis to treat forehead lines. Injections should be above the lowest forehead line seen when the patient contracts the frontalis muscle to raise the eyebrows. Injections should be kept at least 3 cm above the brow. Higher concentrations of Botox allow for more exact placement of the drug with a longer lasting effect and fewer adverse effects. Injection of lower concentrations of Botox in larger volumes of fluid lead to more spread of the toxin, possibly into unintended areas. The area of paralysis is about a 1-1.5 cm diameter around the injection site. The patient should stay upright, exercise the muscle frequently for 4 hours, and avoid rubbing the area. Brow depression is more common if the forehead and glabella (area between the eyebrows) is treated at the same time.

The eyelid can droop as well if Botox leaks into this area. It is seen when the glabella is treated between 48 hours and 2 weeks after injection. It may last 2-12 weeks. To avoid this complication, large volumes of Botox solution is avoided, and injections kept 1 cm above the bony rim above the eye. Patients again should sit up and not rub the area. Other complications include double vision, inability to completely close the eye, too much white of the eye showing, or a disfigured smile (if the toxin spreads to the cheek muscles). For upper eyelid sagging, apraclonidine (Iopidine 0.5%) eyedrops 1-2 drops 3 times a day can be used until the drooping goes away.

Before and after treatment of eyelid drooping

Botox Therapy: Treatment Around the Eye

Periocular Treatment Around the Eye

This involves treatment of undesirable eyelid position and Crow’s feet wrinkles. Eyelid position should be evaluated.

Ideal eyelid position

The normal upper eyelid covers 1-2 mm of the iris of the eye, while the lower lid sits at the lower margin of the iris. The white of the eye therefore should not be visible at the north or south border of the iris of the eye. The distance between the upper and lower eyelid margins should be about 8-11 mm. The lower lid normally is 2 mm higher at the outside end compared to the inside end. Lower lid tone can be evaluated using the snap test. The lower lid is pulled down then allowed to snap back. A slow return to position is abnormal. This means special care is needed treating below the eye. The orbicularis oculi muscle surrounds the eye. It forces the eyelids closed. It is divided into 3 circular bands. If one band is paralyzed by Botox and another contracts the eyelid and lashes can be turned into the eyeball. The orbicularis oculi muscle should be felt to assess its size and shape. The dose and spread of Botox depends on these findings.

The levator palpebrae superioris muscle is in the upper eyelid and raises it. The second muscle in the upper lid is Muller’s muscle. It is not affected by Botox so if the levator palpebrae is paralyzed by Botox and the lid droops, apraclonidine drops can be used to stimulate Muller’s muscle and raise the lid.

Cross section of the upper eyelid

Crow’s Feet
Lines fanning out from the outside corners of the eye are called Crow’s feet. They become more evident when the orbicularis oculi muscle contracts. Crow’s feet worsen with sun damage to the skin, loss of fat, smoking, and prolonged squinting seen in fisherman, and lifeguards. Sometimes the wrinkling is caused by the cheek muscles pushing the skin up towards the eye. This is hard to treat and risks deforming the smile.

Before and after treatment of Crow’s feet with Botox

Injection sites for the treatment of Crow’s feet

Best case for Botox is mild to moderate wrinkles, or treatment of the “jelly roll” that protrudes under the eye when smiling. Botox should be used cautiously in patients with dry eyes, especially associated with Sjogren’s syndrome or rheumatoid arthritis, and also with eyes that don’t close well.

Patient Evalulation
A medical and surgical history should be done including prior plastic surgery, filler injections, or Botox use. An eye history should include tearing, dry eyes, and previous LASIK surgery which causes a higher incidence of dry eyes. Botox may worsen eyelid function and worsen dry eyes. Graves disease, Hashimotos thyroiditis, and collagen vascular diseases can affect the eyes as well.

The facial features are assessed. The resting wrinkles, eyebrow and eyelid position, and forehead wrinkles are checked. Forehead wrinkles may mean the patient is using the frontalis muscle to lift the drooping brow to see and thus treatment of the frontalis muscle may need to be avoided. If too much white of the eye is showing above and below the iris of the eye then further evaluation from an eye specialist is needed. Hidden brow sagging can be checked for. Tell the patient to relax the forehead. If the brow droops, Botox may not be used on the forehead. The patient should then close the eyes to make sure the lids do close. Then they should be forced closed to check for bulging of parts of the orbicularis oculi muscle that can be treated. Crow’s feet should be assessed from the front and sides.

Treatment Goals
Botox may treat Crow’s feet, elevate the brow, or treat the bulging part of the orbicularis oculi muscle in the lower lid. Only lines caused by the orbicularis oculi muscle should be treated. Going too low toward the cheek muscles will cause a disfigured smile. A tendency to under treatment may be safest. Patients can return in 2 weeks for touch up injections. Botox can be used to treat the jelly roll under the lower eyelid from a bulky portion of the orbicularis oculi muscle. However, if this is from excess eyelid skin, or skin pushed up by the cheek muscles, Botox will not help. Therefore a careful exam needs to be done.

If anesthesia is used, ice can be applied immediately before injection or anesthetic ointments can be applied. Usually 2-3 injections are done outside of the lateral corner of the eye, using 4-7 units/site, 12-20 units/side. Injection sites are marked with the person smiling maximally. The first shot is placed to the center of the area of the most wrinkling, 1-2 cm outside of the corner of the eye. The next 2 injections are 1-1.5 cm above and below the first. Injections should be done with the subject not smiling to keep Botox out of the cheek muscles. The effects should last about 4 months.

Complications
Injections may cause pain and bruising. Anesthesia with ice, anesthetic creams, and cold air chillers can help to avoid the bruising. Injections at the outside corner of the eye should be into the skin or fat and no deeper, not into the muscle. Brow and eyelid drooping has been described. A normal brow but only eyelid sagging may respond to apraclonidine eye drops, 3 times a day usually for 2-4 weeks. Other abnormal eyelid position can result in too much eye white showing or the lid border and lashes may curl into the eyeball. Tearing or dry eye from Botox getting into the lacrimal gland can occur. Needle injury to the eye or muscles that move the eye are rare.