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.

Botox Therapy: Lips, Mid and Lower Face

Botox for the Lips, Mid, and Lower Face

Botox can help the lines that extend up and down from the upper and lower lips (lipstick lines), soften deep folds going from nose to mouth corner (nasolabial fold), and diminish the lines running from the mouth corner toward the chin (mesolabial fold). It can make the lip longer, and smooth out the chin. Botox will help mild-moderate wrinkles. More severe problems require fillers, laser therapy, or surgery.

Patient selection is the most important factor for successful cosmetic procedures. Wrinkles are smoothed by relaxing the facial muscles but not to the point of completely paralyzing the face and causing complications. Therefore, there may be a tendency to under treat initially and bring patients back for touch ups. People expecting huge changes immediately will be disappointed. People who require optimal control of the mouth like singers may risk compromising their careers. Because areas around the mouth are heavily worked (eating and talking), the Botox will wear off sooner there.

General Techniques
Good pictures should be taken before and after treatment to document results. Patients need to sign informed consent forms. Blood thinners are stopped 2 weeks before. Target muscles are identified with the patient contracting and relaxing the area several times. The area is cleaned and target muscles marked. Ice can be pressed on the skin immediately before injection for anesthesia and to help avoid bruising. Patients are treated setting up in a mechanical chair that can be flattened out of they become dizzy.

Wrinkles Around the Mouth
Lines around the mouth are from the orbicularis oris muscle that encircles the mouth. They worsen with age, smoking, and sun exposure. This muscle is necessary to close the mouth, to chew, to speak, and to show what mood your in. Botox is often used with fillers like collagen or Restylane to fill in deeper lines.

Botox may increase lip fullness. 1-2 units are injected at four evenly spaced spots along the upper lip margin. 1-2 units can be put along the lower lip border as well. Follow up can be done at 2 weeks and additional 1-2 unit injections can be given. Improvements do not last as long as on the fore head, and injections are needed every 2-3 months for best results. The side effects include an asymmetrical appearance and trouble kissing, sipping, and speaking. Complications can often be avoided by decreasing the dose by as little as 1 unit.

Injection sites for Botox treatment of vertical lip lines

Examples of vertical lip lines

Lip Lengthening
The gummy smile occurs when the levator labii superioris alaquae nasi (LLSAN) muscle pulls up the lip too high and exposes more gum than teeth. Injection of the LLSAN elongates the upper lip to show less gum during a smile. 1 unit is injected into the groove just outside of the nostril. A 2-3 week follow up is done with the option of more injections if necessary. Up to 5 units can be injected at each site. Risks include a disfigured smile with lip sagging, lip protrusion, and lopsided results. Overdone lip elongation can make you look like you have no teeth.


Before and after treatment for the “gummy smile”

Nasolabial Folds
The nasolabial fold is the groove that runs from outside the nostril to the corner of the mouth. In younger people in their 30-50’s, this is more from muscle activity and is better suited for Botox therapy. However, in older folks, cheek sagging contributes more to this fold and they may be better served with injectable fillers or face lifts.

Injecting the LLSAN helps smooth the upper and middle part of the fold. Injecting the cheek muscle may help but risks leading to sagging at the mouth corners. This may resolve in about 6 weeks. Marionette lines or drool lines are grooves that run from the mouth corners to the outer aspects of the chin. They are caused by activity of the depressor anguli oris muscle. It makes people look sad or angry. Treatment of this muscle can raise the corner of the mouth and give one a happier look.

Raising the mouth corners by injecting the depressor anguli oris muscle

When used with fillers, it can smooth out the drool grooves. Botox, 1-2 units is injected into each side. After 2-3 weeks more can be given with a maximum dose of 4-7.5 units per side. The injections must be placed just right. Too far inside and the lower lip sticks out making you look like Gomer Pyle. Injections too far outside hit the deeper chewing muscle and leads to biting and tearing up the inside of the mouth.

Chin Softening
An overactive mentalis muscle causes the apple dumpling or peach pit chin. It can cause a cleft in the chin as well. Peach pit chin is injected with 2.5-5 units of Botox at the end of the chin. The cleft chin is treated with 2 injections of 2.5-5 units each to get both bands of the double muscle. A total of 10-15 units can be given. Risks include trouble with speech and closing the mouth.


Injecting the mentalis Before and after treatment of the peach pit chin

Botox for the Neck

The skin on the neck can be damaged by the sun causing discoloration. It can loose its resiliency, and sag. The muscle can form cords that stick out. The fat can shift around creating hanging pockets. Lasers help the discoloration, while liposuction addresses the fat. But the necklace lines and cords or bands can be treated with Botox.

History
Patients should be asked what about the neck they want improved. They can bring in pictures of when they were younger to help illustrate this. Neck injection should be avoided in patients with neck weakness, swallowing problems, or chronic neck pains. Patients should be evaluated for neck bands, necklace lines, abnormal appearing skin, fat collections, and abnormal jaw shape with the patient at rest and neck contracted. The patient is instructed to clench their teeth and pull down the corners of the mouth to show the neck bands. The operator will pinch the band between the thumb and finger and inject the band. 3-10 units are placed into each site every 1-1.5 cm along the entire length of the band. Thin bands will need 15-20 units and thick bands may need 30 units. A total of 50-100 units can be used. More may risk neck weakness and swallowing problems.


Injecting neck bands Injection sites of neck bands

Before and after treatment of neck bands

Neck lines are treated with 1-2 units every 1 cm along the wrinkle. Injections are into the skin. Deeper injections may cause swallowing problems. Improvement may be noted at 5-14 days. 98.5% of patients in one study, from patient and physician input, reported good to excellent results. Side effects include swelling, redness, bruising, muscle soreness, neck weakness (can’t bend the neck forward while lying down), headaches, hoarseness, and swallowing problems. Patients should not rub the area for 24 hours and not lie flat for 4 hours. Complications usually resolve in a few weeks. Ice can help the bruising and pain.

Botox Therapy: Combination Treatments

Combination treatments

Botox can be used with other therapies to maximize results. Injectable fillers like collagen and Restylane can fill in deep grooves. Laser resurfacing therapies can rejuvenate the skin. Plastic surgery can remove excess tissue and lift sagging areas.

Botox with Fillers
Botox decreases muscle movement and can make filler implants last longer. Fine wrinkles and deeper folds can be treated at once with this combination. Areas include the glabella (area between the eyebrows), the forehead, nasolabial folds, the neck, and other areas around the mouth. Botox is injected about 1 week before filler implants. Freezing the muscle movement prevents trauma and movement of the implant.

Botox and Laser Resurfacing
Botox just before laser resurfacing of the skin holds the area of laser treated skin still, so it can heal and remodel without the folding effects of muscle that created the wrinkle in the first place. The improvements after combination therapy last longer, and Botox can be given every 6-12 months instead of 3-6 months to sustain wrinkle free status. Combination therapy can be good for lipstick lines, drool grooves, forehead lines, and Crow’s feet.

Intense pulsed light (IPL) is a new nonlaser, less damaging light source, that can treat discolored skin lesions, and improve skin texture, pore size, and wrinkles. It burns through the deeper layer of the skin to stimulate new healing. Blood vessel and discolored skin lesions are taken care of along with the wrinkles. Improvement is maintained months longer if done after Botox treatments. There are other devices that heat deeper into the skin to tighten the skin to accomplish a nonsurgical facelift. Botox has bee combined with this treatment as well.

Botox can be combined with surgical procedures too. Surgery can be done cutting some of the brow muscles that make it sag. Botox freezes the area so the brow muscles heal evenly in the right places to give a good symmetrical result. Botox can correct the asymmetry after the surgery too. Botox can be used with blepharoplasty where surgery removes excess skin from around the eye. Keeping the area still helps wound healing. After a face or neck lift, muscles continue to pull the skin down and negate the effects of surgery over time. Botox injections may prolong surgical results.

Botox Therapy: Complications

Complications of Cosmetic Botox Therapy

In a poll, 77% of patients treated with Botox for cosmetic reasons felt more comfortable with their body. Greater than 80% thought the treatment was beneficial, and 100% would recommend it for others. Botox should not be given to people allergic to any part of the Botox preparation. It should not be given to people with unrealistic expectations or who are unsure about it. It should be avoided in patients with some nerve and muscle disorders, who are pregnant, or have skin inflammation over the injection site. Because there is a human protein in the mixture, there is a possible risk of viral disease transmission, although never reported. Some medicines interact with Botox and should be avoided including aminoglycoside antibiotics, cholinesterase inhibitors, succinyscholine, magnesium sulfate, quinidine, calcium channel blockers, lincoamides, and polymixins.

Complications include injection site pain, swelling, redness, and bruising. Allergic reactions from rashes to shock can occur. There was one death reported for someone treated for neck and back pain. Nausea and upper respiratory infections occur but the connection to Botox is unclear. Other side effects include swallowing problems, dry eye, and eyelid droop. There are rare reports of heart attacks and abnormal heart rhythms with noncosmetic use but a direct relationship is not proven. Botulism like in food poisoning is extremely rare. There are other reports of dry mouth, vision changes, and decreased sweating.

Patient Interview
Patients can go through a questionnaire beforehand to give them more time to think about the issues. People with psychiatric conditions must be handled carefully. There is a syndrome called botulinophilia, describing patients who continually seek Botox treatments. There patients should not be treated.

Physical Exam
The patient should be checked for skin infection, rashes, facial asymmetry, scarring, and previous signs of surgery. Patients with thick sagging skin with deep folds that do not improve much when the skin is stretched are not good Botox candidates. Patients with previous eyelid surgery are at higher risk of excessive lower lid sagging. Snap tests on the lower lid should be done to test the tone of the lid. People with already drooping eyebrows or lids are not good for injections to treat forehead wrinkles and risking further sagging. Nonreversible side effects have never been reported. In tests 43.7% of Botox treated patients complained of side effects compared to 41.5% who got a placebo (a fake drug). The most common complaints are headache, cold symptoms, lid drooping, nausea, and pain. Using more concentrated drug injected in lower volumes causes less Botox spread and fewer side effects. This is why patients are also told to remain upright for 4 hours and not rub the area. There is a case report of someone getting Botox into the forehead leading to immediate muscle paralysis. To avoid bleeding patients should avoid taking blood thinners like aspirin and nonsteroidal anti-inflammatory agents for a week. Other products also may thin the blood like vitamin E, ginseng, ginko, garlic, and ginger and should be avoided for 2 weeks.

Forehead
When forehead wrinkles are treated, there is a risk of the brow drooping. Therefore Botox injections must be dept above the mid brow. Muscles that depress the brow can also be injected to raise the brow. Some providers routinely inject the frontalis (forehead) muscle and brow depressor muscles to treat forehead wrinkles and avoid brow sagging at the same time. However, here you risk leaving one with inability to move the eyebrow at all. Eyelid drooping can happen if Botox leaks into the upper eyelid. Apraclonidine (Iopidine) or phenylephrine (Neosynephrine, 2.5%) can reverse the problem. If the outside portion of the forehead muscle is not given enough Botox, it may pull the outside end of the eyebrow up, giving a Jack Nicholson look. Drooping of the eye lid occurs 2-14 days after injection and lasts for 2-4 weeks.

Eyelid drooping Hematoma (bleeding) around the eye

Periocular
When Crow’s feet are treated, bruising can occur. Therefore injections are kept superficial. Using ice helps. Other complications include double vision, inability to close the eye, and upper lip sagging. Eye problems can be avoided by keeping injections 1 cm outside the lateral corner of the eye. If the eye won’t close, it should be taped shut at night and eye drops used until the Botox wears off. Injections below the eye can cause dry eye. When the muscle under the eye is weakened by treatment, the lower eyelid may droop, and too much of the white of the eye will show. Patients at risk for this happening have sagging skin under the eye, already show too much white of the eye pretreatment, or have had lower eyelid surgery.

Lip and Midface
Treatment of smile lines can cause one or both corners of the lip to droop. Other complications include drooling, an asymmetric smile, and problems eating and speaking. Treatment of the neck may be complicated by swallowing problems, hoarseness, and neck weakness.

Lip assymmetry

Laser Therapy for Cosmetic Purposes: Laser Basics

Laser Treatment of Skin
Laser Therapy for Cosmetic Purposes

Laser basics for Skin Treatments

Light is made of bundles of energy called photons. Electrons within atoms will absorb photons and store the energy associated with them. The electrons can release the energy by emitting the photons as a form of radiation. Photons from like atoms have the same energy.


Emitted photons move in waves. A wavelength is measured from the top of one wave to the next. These lengths are reported in nanometers (nm) or in billionths of a meter. Atoms of each material emit photons in specific wavelengths that identify them like fingerprints. Some emitted wavelengths are visible and some are invisible. Humans can see a certain set or band of wavelengths called the visable spectrum. Ultraviolet and infrared energy wavelengths are not visible to the human eye. But they are all part of the Electromagnetic spectrum.

There are basically two ways of making light for clinical uses. They are lasers and pulsed light devices.

The laser emits light energy of one single wavelength and the beam can be focused. Broad band light is emitted as light energy containing multiple wavelengths and cannot be focused.

Pulsed light devices utilize a light source such as a flashlamp that emits energy in a band or multitude of wavelengths from the base of the visible spectrum (400nm) to the border between the near and mid infrared wavelengths (1300nm). The light is directed often through a crystal to the tissue. Some pulsed light devices use filters to limit energy transmission to protect the tissue.

Blocking portions of the spectrum can protect the nontarget tissue to avoid complications. Most filters are high pass devices which block light at and below a specific wavelength. Only light generated above the specified wavelength is emitted to tissue. An example would be a filter to block wavelengths that are absorbed by red blood vessels and allowing through only wavelengths treating specifically brown melanin based lesions like age spots. In this way the age spots can be removed without damage to the surrounding blood vessels.

LASER stands for Light Amplification by Stimulated Emission of Radiation. A laser harnesses an excitation source, often a flashlamp, to drive photons from the laser medium. The light generated has very distinct properties and a single wavelength.

The types of lasers are classified by the type of medium used and the wavelengths of light energy they emit.

Lasers will emit light energy in different ways. It can transmit energy as one continuous beam or break up the transmissions into numerous short pulses.

Light from either device is often delivered to tissue through a hand piece. It may be attached to a fiber optic cord or a hollow arm with directional mirrors within the joints. They commonly use optics to focus the beam to a small diameter or spot size, at a specific distance before tissue contact. When the light comes in contact with tissue there are predictable and controlled reactions.

When light energy is directed at the skin it can be reflected, transmitted, or scattered, none of which cause any clinical effects. However, when light energy is absorbed then significant laser light interaction can take place.

The most common reaction that occurs when laser light energy is absorbed is heating of the tissue. The depth of tissue heated is determined partly by the absorption wavelength.

To be clinically beneficial, enough of the laser energy must be absorbed by tissue to cause thermal damage. This results in ridding tissue of certain unwanted elements.

In tissue there are several elements or structures called chromophores. Each chromophore will selectively absorb light of only certain wavelengths.

Chromophores that are targets for laser light therapies include hemoglobin in red blood vessels (to destroy vascular lesions), melanin in skin pigment (to remove pigmented lesions or unwanted hair), water (to ablate certain levels of skin), and exogenous substances (as ink in tattoo removal).

This slide illustrates the different lasers and their emitted wavelengths and which targets they will treat.

Different types of lasers emitting their different wavelengths will also penetrate skin tissue to different depths.

Erbium and CO2 lasers provide light wave lengths that are strongly absorbed in the epidermis (the outside layer of skin). Therefore, they are heavily utilized for destroying this layer where the wrinkles are as a part of resurfacing procedures.

Visible light or intense pulsed light (IPL), or broadband therapies can penetrate to the deeper dermis for more aggressive resurfacing or treatments that get rid of undesirable skin pigment like age spots.

Basic Laser Priniciples

Basic laser settings, depending on the device, include fluence, power, pulse width, and spot size. The amount of energy delivered to the tissue is measured in joules. The amount of energy delivered per unit surface area is called the fluence, or joules per centimeter squared. Some laser settings are displayed in watts. One watt is one joule of energy delivered over one second. For lasers that deliver energy in pulses rather than continuously, the amount of time the laser is on during a pulse is called the pulse width, measured in seconds, milliseconds, even nanoseconds. The spot size is the size of the target area hit by the laser.

The interaction of laser energy with tissue
The amount of energy that is within a laser beam is related to the wavelength. There is more energy in the photons of a laser beam of shorter wavelength than of longer wavelengths. In fact a beam with a wavelength of 532nm delivers twice as much energy per unit than a wavelength of 1064nm. Laser photons can be relected or absorbed. When absorbed by a target molecule called a chromophore, the molecule will undergo a change which could be damaging. Each chromophore will tend to absorb light energy of only certain wavelengths. When treating skin, there are three main chromophores that are being targeted; water, hemoglobin (blood), and melanin (skin pigment). Water will absorb wavelengths at primarily 980nm, 1480nm, and 1060nm, with a maximum at 2940nm. Hemoglobin will absorb at 415, 540, 577, and 940nm. Melanin absorbs wavelengths <800nm.>

Exposing wide areas of tissue to laser energy but damaging only selected targets like blood vessels or hair relies on a principle called selective photothermolysis. In this way laser energy is delivered with a wavelength that is absorbed only by the target chromophore say melanin. If enough energy is delivered, the target lesion containing melanin (say hair follicles) will be destroyed without harming surrounding skin that do not absorb that particular wavelength. This would be like launching smart missiles that hit only the desired targets.

Preventing damage to tissue around the target chromophore relies on the principle of the thermal relaxation time. The thermal relaxation time is the amount of time it takes for the target to cool a certain amount from the peak temperature achieved. For a lasered target it is the amount of time it takes for the target to cool off after the laser pulse is given. So, if the pulse is too long, the target can cool off during the pulse. Just like trying to slowly fill a bucket with a big leak. The bucket will never fill. In the same way if cooling is taking place during laser heating, the target may never reach the temperature high enough to destroy it. Therefore, the pulse width or duration of a laser pulse is set at less than the thermal relaxation time to assure all of the destructive energy is delivered to damage the target before it has a chance to cool off. If the pulse width is too short, the pulses can vaporize the target, a more explosive result that yields more damage to target blood vessels with more bleeding and unsightly bruising. Longer pulses can more gradually heat damage targets without blowing up the vessels.

Lasers can treat skin lesions in other ways other than with heat damage. Lasers can be used to stimulate chemical reactions to destroy tissue. One example is with treatment of acne. A chemical called aminolevulinic acid is spread on the skin where cells in sebaceous glands convert it to PPIX. When PPIX is hit with photons, it is converted to an oxygen radical that destroys acne causing gland cells. Light therapy can also cause biostimulation. LED light can supposedly increase collagen tissue formation in the skin to tighten and firm up aging facial skin.

The skin has two basic layers, the epidermis or outer layer and the dermis or underlying layer. The epidermis absorbs most of the light exposure because most of the melanin giving skin its pigment is located there. The dermis contains several of the target chromophores including blood vessels and hair follicles. It also contains collagen tissue that supports the skin and gives it its tone. There are several different kinds of lasers with various applications. The violet intense pulsed light and LED lamps can treat acne. The 940nm and 1064nm Nd:YAG lasers are used for resurfacing to treat wrinkles. Wrinkles and scars are also addressed with CO2 or Er:YAG lasers. Spider veins and telangiectasias can be treated with 1064nm lasers or intense pulsed light (IPL). 1064nm lasers can be used for unwanted hair removal from the face and back as well.

Cooling
When deeper targets in the dermis are approached with a laser, especially hair or blood vessels, the outer layer of skin, the epidermis, may be damaged because melanin in this layer absorbs laser light as well. This can result in burning, crusting and scarring of the epidermis. To avoid this, the epidermis is cooled to protect it from heat injury while laser energy passes on through to targets in the dermis. Surface cooling can be achieved with ice, cooled gels, and cold glass or sapphire plates the laser can pass through. Devices like the Zimmer chiller blows cold air on the site to keep it cool. Cooling can also result in pain reduction as well with laser treatments.