BOTULINUM TOXIN in VS .NET

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CHAPTER 22 BOTULINUM TOXIN
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Depressor supercilii portion of the corrugator
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FIGURE 22-8 The depressor supercilii is a branch of the corrugator muscle responsible for depressing the medial eyebrow Massaging the toxin into this area usually causes elevation of the medial brow
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BROW LIFT AND THE MICRODROPLET TECHNIQUE
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FIGURE 22-9 Female patient A before and B after 12 units to the glabella Note that she is recruiting facial muscles in the center of the brow in order to frown BTX has been used to elevate the eyebrow position by treating between the eyebrows as well as the lateral eyebrow with relatively few injection sites,23 and with relatively large quantities of BTX (15 25 U BTX-A)40 This technique is limited by the possibility of inducing the undesired side effect of upper eyelid ptosis caused by the unwanted diffusion of BTX into the levator palpebrae superioris muscle, which is responsible for eyelid elevation41 The position and appearance of the eyebrows is determined at rest and dynamically by the opposing action of several groups of muscles that act on the eyebrow The frontalis muscle primarily performs eyebrow elevation Brow elevation is opposed by the septal and orbital portions of the orbicularis oculi muscle, including the depressor supercilii component of the orbicularis oculi muscle, and the procerus muscle42 The medial position of the eyebrow is also influenced by the activity of the corrugator
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FIGURE 22-10 The pattern of injection to encourage arched browsThis pattern is used to promote a more feminine brow shape Each x denotes 4 Botox units or 500 Myobloc units
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FIGURE 22-11 The pattern of injection to encourage horizontal brows This pattern is used to cause a more masculine brow shape Each x denotes 4 Botox units or 500 Myobloc units
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FIGURE 22-12 Before (A) and after (B) injection of Botox in the V-shaped pattern taught by many BTX experts However, in this patient, signi cant use of the lateral forehead muscles is seen in A Using the V-shaped injection technique in a patient with this forehead muscle function results in an unpopular Diablo eyebrow as seen in B This can be avoided or corrected by injecting 4 units of Botox 2 cm above the lateral brow in the area of muscle movement
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FIGURE 22-13 This patient was treated with Botox in the forehead by a beginning BTX injector On her right side the lateral forehead was treated On the left side it was not It is crucial to inject the forehead equally on both sides to prevent asymmetry
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supercilii muscle Additionally, the shape of the brows is affected by the activities of the eyebrow elevators and the eyebrow depressor muscles where they interdigitate along the eyebrow to create facial expression43 With age there is a gradual fall in the position of the eyebrows, which is known as brow ptosis, resulting in smaller appearing eyes that is not aesthetically desirable BTX can also be used to elevate the brows, resulting in a more youthful appearance This has been referred to in the literature as a chemical brow lift The technique of lifting the brow includes injection of the glabellar area as described above After injecting the procerus muscle with 01 cc of Botox the nasal bridge should be massaged in order to ensure that the toxin enters the depressor supercilii portion of the corrugator muscle as shown in Fig 22-8 This can be used to try and correct an asymmetry of the medial brow Injecting 005 cc of Botox into the lateral brow depressor muscles as shown in Fig 22-23 can raise the lateral aspect of the eyebrow44 Ahn et al showed that treatment of the lateral depressors of the brow results in an average brow elevation of 483 mm when measured from the lateral canthus45 Injections of Botox into the glabellar area and lateral brow have also been shown to yield brow elevations of 1 to 3 mm when measured from the eyebrow to the midpupillary point44 However, it is the primary author s experience that the lateral brow lift with Botox provides inconsistent results and leads to lateral brow lowering in some patients (The procerus injection consistently raises the brows) Therefore, the lead author prefers using a dermal filler injected into the lateral brow to achieve a brow lift ( 23) A novel technique introduced by Steinsapir is intended to temporarily elevate the eyebrows without provoking any undesirable side effects This microdroplet technique uses small quantities of BTX dissolved in microdroplets of injectable saline carrier to treat the septal and orbital orbicularis muscles, on each side of the patient s face He treats the frontalis at and below the brow by injecting very small volumes of fluid in multiple locations46 These microdroplets have volumes of 10 to 50 L of injectable saline containing as small as 0001 to 1 U Botox Treatment is based on 100 U Botox and 3 mL of injectable saline, which equals approximately 033 U of Botox per 10 L A typical treatment involves a total of approximately 100 microdroplets placed in double or triple rows just above, in, and
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