new procedures in facial plastic surgery using botulinum tox

8/13/2019 New Procedures in Facial Plastic Surgery Using Botulinum Tox

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New procedures in facial plastic surgery using

botulinum toxin A

Howard D. Stupak, MDa, Corey S. Maas, MDa,b,*

aDivision of Facial Plastic Surgery, Department of Otolaryngology - Head and Neck Surgery,

University of California at San Francisco, 400 Parnassus Avenue, San Francisco, CA 91143-0342, USAbThe Maas Clinic, 2400 Clay Street, San Francisco, CA 94115, USA

Botulinum toxin is a potent neurotoxin that is

produced by the bacterium Clostridium botulinum.

The agent causes muscle paralysis by preventing the

release of acetylcholine at the neuromuscular junction

of striated muscle. Botulinum toxin A (Botox, Aller-

gan Inc., Irvine, California) is the most potent of seven

distinct toxin subtypes that are produced by the bac-

terium[1]. The toxin was first used clinically in the

treatment of strabismus caused by hypertonicity of the

extraocular muscles[2].The toxin was subsequently

described in the treatment of multiple disorders of

muscular spasticity and dystonia [3,4]. In treating

patients with Botox for blepharospasm, Carruthers

and Carruthers [5] noticed an improvement in glabellar

rhytids. This ultimately led to the introduction and

development of Botox as a mainstay in the treatment of

hyperfunctional facial lines.

Since its approval by the U.S. Food and Drug

Administration for the treatment of facial rhytids

in 2002, botulinum toxin A has exploded onto the

marketplace and into widespread national use. When

treating facial rhytids, most physicians are most com-

fortable using Botox in the upper third of the facewhere results are the most well-described, noticeable,

and predictable [6]. Forehead, glabellar, and periocular

rhytids are the most frequently treated facial regions,

and excellent results have been documented. [6,7]

Indications for alternative uses for Botox in facial

plastic and reconstructive surgery are expanding.

These include a variety of well-established procedures

that use Botox as an adjunctive agent to enhance

results. In addition, Botox injection is finding in-

creased usefulness as an independent modality for

facial rejuvenation and rehabilitation. The agent is

used beyond its role in facial rhytids as an effective

agent in the management of dynamic disorders of

the face and neck. Botox injection allows the physi-

cian to precisely manipulate the balance between

complex and conflicting muscular interactions, thus

resetting their equilibrium state and exerting a clini-

cal effect. This article reviews some of the new and

unique procedures that use Botox as their primary

modality. The procedures described are not meant

as a replacement for surgical management, but to serve

as an adjunct to surgery or to provide alternatives

to patients who are unable or unwilling to undergo an

operative procedure.

Pharmacologic browlift using botulinum toxin

One of the most frequently treated areas of hyper-kinetic facial wrinkles is the horizontal and vertical

lines of the glabellar region. The muscles that are

targeted are the corrugator and procerus, two of the

primary depressors of the medial brow. It was observed

that weakening of these muscles by either botulinum

toxin injection during treatment of glabellar furrows or

actual muscle lysis during browlift results in some-

times significant changes in brow elevation[8].These

observations led to the design of minimally invasive

techniques to manipulate the position and shape of the

brow. These techniques are based upon the principle

that brow position is the result, at least partially, to the

1064-7406/03/$ see front matterD 2003 Elsevier Inc. All rights reserved.

doi:10.1016/S1064-7406(03)00092-0

* Corresponding author. The Maas Clinic, 2400 Clay

Street, San Francisco, CA 94115.

E-mail address:[email protected] (C.S. Maas).

Facial Plast Surg Clin N Am 11 (2003) 515520


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vector of force (Fig. 1)resultant from the equilibrium

between brow depressors (orbicularis oculi, depressor

supercilii, procerus, and corrugator muscles) andthe

primary brow elevator (the frontalis muscle)[9]. By

selectively weakening the depressor musculature, the

frontalis muscle acts unopposed and the resting browposition is elevated to a more superior position [912].

Endoscopic browlift relies on these identical prin-

ciples, where lysis of the corrugator and procerus

muscles permits a favorable vector equilibrium state

for repositioning of the brow periosteum [13].Simi-

larly, several investigators proposed techniques to

modify the contour and position of the brow by

selective weakening of its elevator or depressor

muscles using targeted botulinum toxin A injection.

Frankel and Kamer [8]evaluated a technique for

medial brow elevation. They injected 20 U of botuli-num toxin A into the glabellar region of patients who

had either glabellar rhytids or depressed medial brows.

They found an elevation of the brow in 32% of patients

at the medial canthus and 48% of the patients at the

midpupillary line. Quantitative measurements were

not displayed in this paper. Blinded observers found

a subjective increase in brow elevation in 62% of

patients. Although the results were not dramatic in

this initial study, the concept of brow elevation without

surgery was validated.

Fagien[14]suggested that injection into the browcould be done in a creative fashion, finely adjusting

brow position with selective elevation and depression

of various brow locations. Isolated medial brow ele-

vation or the surprised look is seen as a less

desirable aesthetic outcome. Lateral or temporal brow

elevation, conversely, is more consistent with the ideal

eyebrow shape, where the highest point of the brow is

located directly above the lateral limbus [15] or, as

more recent data suggest, even closer to the lateral

canthus[16].This eyebrow shape is associated with a

more natural and youthful appearance. Ahn et al [9]attempted to achieve temporal brow lifting by way of

far more lateral injections than the previous study.

They injected botulinum toxin A into the temporal

orbital portion of the orbicularis oculi muscle. Twenty-

two patients were treated with 7 to 10 units of botox to

the superolateral portion of the muscle. Care was taken

to ensure that all injections were administered supero-

lateral to the orbital rim, to avoid diffusion of toxin

through the orbital septum and into the orbit.

Brow elevation was measured with calipers at

the lateral brow and at the midpupillary line (Fig. 2).

The degree of elevation was only an average of 1 mmat the midpupillary line, but was 4.8 mm at the lat-

eral canthus (Fig. 3). Although results were modest

and sometimes unpredictable, the investigators sug-

gested that the technique may provide an alternative

temporal browlift in patients who are reluctant or

unable to undergo surgery. Others describe the usage

of Botox injection into the brow region as an

adjunctive to endoscopic browlift for the weakening

of glabellar musculature.

Huang et al [12] also looked at the ability of

botulinum toxin A to achieve lifting of the brow. Theycombined medial and lateral injection techniques,

using 10 units at the lateral orbital rim and 5 units at

the corrugator medially. They measured elevation

using digital photography 7 to 10 days postinjection.

Their results showed maximal brow elevation in the

central brow in relaxed and elevated positions. These

investigators proposed that central brow elevation is

the most aesthetically pleasing position.

Complications reported in the studies of botuli-

num toxin A brow elevation were few, and included

slight bruising, transient potashes, or brow depres-

sion. Although all of the studies showed substantialbrow elevation in most subjects, results were unpre-

dictable in many patients, and the study populations

Fig. 1. (A) Vectors of muscular pull in the brow region and

injection sites (X) for lateral brow lifting. This is accom-

plished by weakening the depr essor function of the

orbicularis muscle which allows the lateral frontalis muscle

to act unopposed. (B) Injection of botulinum toxin A into the

lateral orbicularis muscle. (See also ColorPlate 18.)

H.D. Stupak, C.S. Maas / Facial Plast Surg Clin N Am 11 (2003) 515520516


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were small (see references [8,9,12]). Each of the

three studies described the site of ideal maximal brow

elevation at a different location: medial [8], central

[12], and lateral [9]. None of the studies addressed

patient satisfaction, nor compared the various tech-

niques. Recent data on the evaluation of 200 frontal

photographs of fashion models and randomly selected

individuals strongly suggested that the highest point

in the aesthetically pleasing female brow isfairly far

lateral, almost over the lateral canthus [16].

Brow lifting and sculpting using botulinum toxin

A can be accomplished. This technique is useful in a

patient who is not a surgical candidate or who is not

interested in surgical procedures. The complicationrate is low, but the results remain unpredictable, and,

in some case, subtle. Further studies with larger

patient populations may be useful to determine ideal

injection sites and dosages.

Rehabilitation of facial asymmetry using

botulinum toxin

The paralytic effects of botulinum Toxin A can be

useful in the treatment of facial asymmetry that is aresult of hyper- or hypofunctional problems. Botox

was initially used to weaken hyperfunctional facial

musculature that was caused by hereditary or post-

paralytic hemi-facial spasm[1719]. Indications for

this treatment were eventually expanded to include

the management of aberrant facial nerve regeneration

after facial paralysis. Aberrant regeneration of facial

nerve fibers after facial palsy may lead to several un-

wanted effects, including involuntary synkinesis be-

tween the orbicularis oculi and orbicularis oris muscle

(Fig. 4)or increased lacrimation of the affected eye,

Fig. 2. (A) Brow position before botulinum toxin A injection

to the lateral orbicularis muscle. (B) Brow position 2 weeks

after botulinum toxin A injection to the lateral orbicula-

ris muscle. (See alsoColor Plate 19.)

Fig. 3. Measurement of brow height using calipers at the

lateral canthus. (See alsoColor Plate 20.)

Fig. 4. Patient partially recovered from left-sided facial

paralysis smiling, demonstrating synkinesis of the orbicu-

laris muscle and distorted smile caused by a pull from the

contralateral perioral musculature. (See alsoColor Plate 21.)

H.D. Stupak, C.S. Maas / Facial Plast Surg Clin N Am 11 (2003) 515520 517


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especially during salivation [20]. Several studies

demonstrated that selective injection of Botox into

the orbicularis oris can reduce the synkinetic phe-

nomenon of involuntary eye closure with facial

movement in most cases [2023]. In addition,

patients with injection into the lateral orbicularis mus-cle or with direct injection into the lacrimal gland

had a reduction in hyperlacrimation [20]. Direct in-

jection into the lacrimal gland seems to have a more

potent effect. Side effects in treated patients were

frequent; up to 6 out of 10 patients in one studyhad

side effects that were fully reversible in all cases [20].

The most common complications included transient

lid ptosis, lagopthalmos, or transient facial weak-

ness. In addition, the investigators reported less

frequent cases of transient diplopia and several epi-

sodes of conjunctivitis, symptoms of exposure kera-topathy[2023].

More recent studies focused on the usage of botox

in the rehabilitation of patients wio had a unilateral

hypofunctional facial asymmetry. Botox acts in this

situation by weakening the contralateral musculature,

to create a more balanced, harmonious appearance.

Several studies showed an improvement in the asym-

metry that was caused by facial nerve paralysis or

paresis. Clark and Berris[24]presented a case report

where botulinum toxin was used to weaken a contra-

lateral brow in a patient who had isolated postsurgical

frontal branch weakness. They used 12 units of botu-

linum A toxin and found subjectively excellent im-

provement in asymmetry, which lasted for 2.5 months.The temporary, yet long-lasting, nature of this therapy

is advantageous, because most traumatic, idiopathic,

or postsurgical nerve injuries recover in a matter of

months without requiring surgical reanimation[25].

Bikhazi and Maas [26] evaluated the ability of

botox to not only weaken the contralateral facial

musculature for its effects on facial balance, but for

its effects in decreasing the distortion of the face by

decreasing excessive pull from the nonparalyzed side

during facial expression. This pull is particularly

caused by the perioral facial musculature duringexpressions such as smiling (seeFig. 4). In their study,

10 patients received 10 to 25 units of botox that was

injected into the zygomaticus major/minor muscles,

levator labii superioris, risorius, or depressor anguli

oris muscles. The site of muscular injection was

determined by the location of maximal muscle pull.

Eight of the 10 patients reported either moderate or

marked improvement in their smiles. Complications

Fig. 5. (A) Platysmal banding before botulinum toxin A injection. (B) Platysmal banding 2 weeks after botulinum toxin A injection.

(See alsoColor Plates 22 and 23.)



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were minimal, except for one patient who described

a restriction of her normal smile that persisted for

2 months. The investigators noted that an advantage

of this technique was that an injection could be

targeted to specific locations and dosage could also

be titrated over time to avoid complications.

Management of platysmal banding with

botulinum toxin A

The platysma muscle is a sheet of vertical mus-

cular fibers that extend from the surface of the man-

dible to the upper chest. The primary role of the

muscle is to tense the skin of the neck, but it also

contributes to the appearance of aging in the neck.The anterior/medial fibers of the platysma muscle

contribute to the process of the aging neck by gradual

weakening and loss of connection with the fascia of

deeper planes. The interdigitation between the pla-

tysma muscle fibers on either side is highly variable.

The significant dehiscence that is found between the

two sides in some patients results in the appearance of

vertical platysmal bands in the neck upon muscular

contraction[27]. The platysma may play a role in the

horizontal lines of the neck through hyperkinetic

activity and in jowling by depressing the skin and

underlying soft tissue of the upper neck[6].Several studies looked at the usage of botulinum

toxin A in the management of platysmal bands. Mat-

arasso et al[27]evaluated more than 1500 patients in

several practices. High doses of botulinum toxin A,

between 30 and 100 units depending on the degree of

banding, were injected into each platysmal band at

three to five sites per band. Patients were asked to

grimace; neck bands were identified, grasped, and

injected. They found the best results in patients who

had mild to moderate banding, where 98.5% of

patients had good to excellent results (Fig. 5). Detaileddata analysis was not provided. Another group of

investigators treated 26 patients with botulinum

toxin A for their platysmal bands[28].Smaller doses

(5 to 20 units per band) were used, with subjective

improvement in most cases. They noted that improve-

ment was more noticeable during dynamic platysmal

contraction than at rest.

Significant complications, including dysphagia

and neck weakness, have been reported as a result of

the diffusion of the toxin into deeper neck muscula-

ture, especially during higher-dose injections [6,27].

These sequelae can be minimized by maintaining asuperficial plane of injection. Other transient compli-

cations included edema, ecchymosis, and neck pain.

Summary

New indications for botulinum toxin A injection

in facial plastic surgery have begun to emerge beyond

the management of facial rhytids. This paper de-

scribed a role for botulinum toxin in the rehabilitationfrom facial nerve paralysis, in the pharmacologic

browlift, and in the nonsurgical management of

platysmal bands. These procedures are not meant as

a replacement for surgery, but rather as a less invasive

alternative, or as an adjunctive modality. They are

most useful in cases of functional or dynamic dis-

orders, as opposed to problems of excessive or lax

tissues. This article presented several clinical studies

that give supportive evidence for the efficacy of the

procedures. Further, larger studies with more objec-

tive measurements are necessary before these proce-dures become widely accepted.

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