Botulinum therapy as a method of correcting age-related manifestations

The revolution in the form of the use of botulinum toxins burst into the world of aesthetic medicine more than twenty years ago and has long gone beyond the strict limits of application according to instructions, on the label. Probably, every experienced specialist considers himself to have the right to regulate the dose of the drug, its dilution, and especially the area of ​​application, based on the individual characteristics of the patient.

Over the twenty years of the era of botulinum toxins, several waves of their perception have changed: we began with an enthusiastic and wary attitude, when doctors, having received a dangerous toy in their hands, tried by hook or by crook to learn how to use it (I often talk at master classes about the tragicomic cases of my first “learning experience”), went through stormy waves of rejection of this product against the background of delusional ideas of the mass media about “Botox in the lips” and “Botox in the brain”, then a stage came when we believed that we knew everything about the use of this product, and Here we are again opening new horizons.

I, like many other specialists, believe that comprehensive facial correction is impossible without this product, and today I do not see a full-fledged replacement for it. Only botulinum toxin preparations can perform the magical function of taming overactive facial muscles. But it is precisely in their relation that the statement of Paracelsus is more relevant than ever: “Everything is poison, the medicine is in the dose.” And I would also add that the medicine is in the dose and at the place of application.

In this article, I would like to cover the topic not of the classic use of botulinum toxin to block facial muscles in its pure form, but of the specifics of its use to obtain a certain lifting of facial tissue. These techniques, in combination with lifting techniques using hyaluronic acid fillers (read an article on this topic in “Les Nouvelles Esthetiques Ukraine”, No. 6, 2014, p. 34. – Editor’s note ) in many cases give a result that can be called non-surgical lifting.

REPEATING ANATOMY

Let's look at the principle of interaction between facial muscles.

We remember that this muscle differs from all other striated muscles of the human body in several ways:

• the muscles are not enclosed in fascia;
• the fibers of neighboring muscles are often intertwined;
• unlike skeletal muscles, all facial muscles, except for the sphincters, are attached to the bone at only one end, and the other is woven into the dermis of the skin;
• muscle fibers are thinner than skeletal muscles;
• muscles often have an individual structure and location (for the g labella complex alone, many authors indicate more than six variants of structure!), caused by the peculiarities of regular emotional manifestations in a person (I am inclined to agree with the somewhat esoteric idea that a person in old age has a face that fully reflects his inner world).

Considering a person’s face in dynamics, we cannot help but pay attention to the existence of two muscle groups:

• depressors - muscles that dynamically pull the skin down and medially;
• suppressors - muscles that dynamically perform the opposite function, that is, a displacement outward and upward.

It is the complex work of these muscles that gives rise to the entire range of facial expressions on the human face. Complexes that perform the function of depressors include the g labella and m complex . orbicularis . The suppressor function is performed, for example, by m. frontalis (Fig. 1).

Rice. 1. Location of suppressors and depressors

Hypocorrection vs hypercorrection

The use of botulinum toxin requires a special approach. We always need to remember about the compensatory function of muscles, about their individual characteristics in each individual patient, in particular about age.

Particular care must be taken in the first place when blocking m. fron talis . Since it is not possible to reliably identify its suppressive and depressive portions, in each specific case these individual characteristics should be palpated.

The correction scheme should be based on many factors, such as :

• muscle pattern (width, presence of a central portion, effect on the eyebrow complex);
• muscle thickness (correlates with strength; with complete relaxation of a large mass, we can get pseudoptosis of the eyebrows);
• features of age function.

Age-specific changes in facial muscles, in particular, include involuntary hypertonicity that occurs in the m. frontalis (most patients experience subconscious discomfort due to the formation of age-related excess tissue of the upper eyelid and involuntarily keep the forehead muscle toned by permanently lifting the eyebrows, which allows to somewhat compensate for the overhang of tissue in the orbital zone). Similar condition m. frontalis causes combined compensatory hypertonicity in the glabellar complex, which leads to aggravation of facial wrinkles between the eyebrows (Fig. 2).

Rice. 2. The mechanism of formation of age-related muscle hypertonicity

A full forehead block in such a situation will not lead to a satisfactory result. Patients will complain of discomfort, the most common problem being “closed eyes”, “dropped eyebrows”.

Thus, in the case of using botulinum toxins, the doctor is in a “fork” state, often choosing a smaller, predictably insufficient effect, compared to the possible problems of a full-fledged block.

EYEBROW COMPLEX: FEATURES OF WORK

It is appropriate to start with the area that first received indications for the use of botulinum toxins, namely the glabellar complex.

Let me remind you of the basic principles of safe injection. In the dynamics of frowning, we evaluate the shape, location and strength of the muscles, the degree of their participation in the formation of wrinkles. We define safety guidelines. These are two vertical lines:

• The first is a vertical line passing through the medial canthus of the eye. Injection into the abdomen m. The corrugator should be located no lower than 1.5 cm from the edge of the orbit up along this line. Even if we do not inject directly into the center of the muscle belly, the normal distribution of the drug, which for any brand of toxin is from 1.5 to 2.5 cm, will block this muscle. Injecting the product into a point located below and lateral to this line can lead to undesirable and not very aesthetic results: the eyebrows diverge too much, the space between them becomes unnatural. In addition, there will be a risk of the drug “flowing” along the supratrochlear notch of the orbit and the risk of true ptosis will increase, the effect of overhanging of the medial fold of the upper eyelid, etc. will be observed. Remember that on top is m. corrugator is covered with m . frontalis .
• The second line is the midpupil vertical straight line . Tail blocking point m. The corrugator should be medial to this rectus so as not to block the muscle that lifts the upper eyelid, which causes true ptosis. Some specialists inject directly into the skin retraction, but in this case we will only block the end fibers of the muscle that are woven into the dermis. The dosage for the second injection point is half the division of the syringe (about 4 units), the injection is intradermal. Blocking m. procerus is performed or not performed depending on the degree of its severity and strength.

Rice. 3. Classic glabellar block

Different experts identify different forms of this complex and recommend doses and points of administration based on certain “average” principles. I believe that each case must be considered individually. The assessment should begin with finding out the shape, length and location of m. corrugat or and its combined interaction with m. procerus . Weak work m. procerus leads to the formation of vertical wrinkles-folds in the area between the eyebrows, formed during counter contraction of m. corrugat or . Such a pattern of facial activity does not require blocking m. procerus .

Rice. 4. Blockade of the eyebrow with inactive m. procerus

Sometimes the central part m . frontalis is so strong that when you frown, it “lifts” the glabellar complex, forming parallel horizontal creases in the lower central part of the forehead. As a rule, this is combined with slightly shortened m. corrugator . The injection pattern in this situation resembles a triangle with its apex facing upward (Fig. 5).

Rice. 5. Blockade of the eyebrow with an active portion of m. frontalis

In a situation where m. is involved in the process of wrinkle formation. compressor naris (in some sources called m . nasalis ) and we see the so-called “cleft wrinkles”, the injection pattern takes on the shape of an “X” (Fig. 6).

Rice. 6. Blockade of the eyebrow with active m. nasalis

Since m. nasalis often takes on a compensatory function when the glabellar complex is turned off; many authors recommend its preventive block. I don't see this as a big problem and often place two intradermal injections right in the center of the creases on the side of the nose.

Despite the fact that many colleagues talk about the greater participation in the formation of “cleft wrinkles” of the upper portion of the m. levator labii superioris (alaeque nasi) , I have come to the conclusion in practice that too often an attempt to block this area leads to the undesirable effect of a deformed smile (the so-called clown smile), while intradermal injection into the skin above the m. nasalis due to normal diffusion (1.5 cm) will have a mild effect on the entire complex, but will not cause such undesirable effects (Fig. 7).

Rice. 7. Correction of “bunny wrinkles”

CORRECTION OF FOREHEAL WRINKLES

This is one of the most popular procedures among our patients. To obtain a satisfactory aesthetic result, we should never forget that m. frontalis is a suppressor muscle and if its activity is blocked, the eyebrows will take on the full weight of this muscle mass. Particular care should also be taken with older patients with the symptom of “permanent compensatory eyebrow raising.”

So, the estimate is m. frontalis:

• we evaluate the width and thickness, strength of the muscle: you should try to simulate the result when it is completely relaxed, demonstrate this result to the patient in the mirror;
• We evaluate the structure of the muscle (are there muscle fibers in the central part, or is there no need to perform an injection in the center of the forehead);
• we determine the “safety line”: as a rule, we visually divide the width of the frontal muscle in half with a horizontal line and do not go below this notional line. Based on my experience, in the vast majority of cases the following turns out: the higher the injection points are to the hairline (within the muscle, of course), the more depressive portions m. frontalis will be turned off and the more lifting effect we will get. If we talk about a very low forehead, when the “safety line” leaves us less than 2 cm of forehead width, then in this situation I reduce the dose and again try to rise as high as possible within the muscle, paying attention not to the pattern of wrinkles, but to the structure of the muscle itself ;
• in older patients, we determine the vector of eyebrow lifting (we ask the patient to be surprised and see how much he can raise his eyebrows compared to his “normal” state);
• We evaluate the severity of hypertronus of the lateral muscle bundles. We take into account that a full block of the entire array will most likely lead to several unpleasant moments:

a) a complete block along the eyebrow lifting vector will lead to its lowering, and the patient will experience the uncomfortable state that I already mentioned above;

b) a complete block of the medial part while maintaining eyebrow mobility (in the case of an older patient) can with a high degree of probability lead to the “Mephistopheles eyebrow” effect.

That is why in such a situation I always convince the patient not to block the horizontal forehead wrinkles. But if I still perform the procedure, then I block the medial part with a soft lifting block, but in older patients I do not affect the lateral part, using soft hyaluronic acid fillers (Teosyal Global Action, for example) to soften skin creases. Even if we are forced to place the injections in the lateral part of the forehead, they should in no case be located at the apex of the eyebrow thrust vector. Their location should be more medial (Fig. 8).

Rice. 8. Correction of forehead wrinkles

"HOUGH FEET"

And finally, we move on to the correction of the periorbital area - “crow’s feet”, or “laughter lines”.

Correction in this zone is based on the following principles:

• assessment of anatomical landmarks: our injections should be located within m . orbo cularis oculi , usually at a distance of about 1–1.5 cm from the bony edge of the orbit;
• assessment of the drainage function of the muscle: visually assess the condition of the tissues and collect an anamnesis. So, if a patient reports that he often experiences significant swelling in this area, and that he has significant filler arrays located in the periorbital zone, a classic muscle block can lead to increased swelling;
• assessment of the condition of the tissues of the infraorbital zone in older patients: with significantly pronounced malar sacs, I prefer not to use an injection into the inferolateral portion of the muscle, so as not to aggravate the condition of the infraorbital zone (Fig. 9).

Rice. 9. Correction of the periorbital area

I perform the first injection at the level of the horizontal line passing through the lateral canthus of the eye, sometimes slightly higher. Its location is 1−1.5 cm lateral to the bony edge of the orbit. Intradermal injection.

The second point is located at the intersection of the most medial fold, formed when the eyes are tightly closed, and the line of the eyebrow. Sometimes this fold even crosses the eyebrow, but it is not advisable to perform an injection above the eyebrow, since in this situation separate suppressive portions of m come into play . frontalis , the switching off of which leads to the formation of the effect of drooping eyebrows. Thus, the second injection is usually located slightly below the “tail” of the eyebrow.

The third injection is performed only if there is no pastiness or swelling. In my practice, in 90% of cases I do not perform correction of the lateral inferior portion of the muscle. If we do not observe any alarming factors, then this injection is performed 1 cm below the line of the lateral canthus, into the crease formed by strong squeezing of the eyes. Cases when the hall leaves the orbital zone and continues in the zygomatic zone are caused by the intervention of m . zigomaticus minor / major . Blocking the fracture below the orbital region with botulinum toxin is fraught with undesirable effects. In this situation, it would be correct to supplement the botulinum block after two weeks with injections of soft fillers.

Below are expert recommendations for aesthetic correction of the most common indications for botulinum therapy in the perioral area, incl. data from the “Consensus of the International Expert Council”.

Radial wrinkles around the mouth (“purse-string” wrinkles)

Radial wrinkles around the lips make the face look very old. Injections of botulinum toxin preparations allow for fairly effective correction of these wrinkles. However, optimal results are achieved by combining botulinum toxin with the introduction of fillers along the border of the red border and in the area of ​​the columns of the filtrum, restoration of lip volume and/or bite correction (if necessary).

The most important role in the correction of static wrinkles and deep skin creases in this area belongs to methods of improving the condition of the skin in the perioral area (biorevitalization, chemical peels, dermabrasion, laser resurfacing, fractional laser remodeling).

When performing BTA injections in the perioral area, it should be remembered that the muscles located around the lips are involved in the implementation of important physiological functions. Therefore, correction of this zone must be carried out very carefully.

Safety considerations: If too high a dose of BTA is administered, functional weakening of the lips may occur, leading to impairment of speech, eating and fluid intake. Since complete removal of wrinkles is not the goal of the procedure, BTA must be injected shallowly and in a minimal dose. To ensure safety, injections should begin with small doses and gradually increase until the desired result is achieved. Lateral points are placed as far as possible from the corners of the mouth to avoid possible asymmetry, drooping of the corners of the mouth and drooling. For patients whose professional activities involve active work of the orbicularis oris muscle, this procedure is not recommended. Correction of lower lip wrinkles using BTA injections is quite risky, so it should be avoided unless necessary.

“Marionette” wrinkles or “bitter folds”

Drooping corners of the mouth make the face sad or dissatisfied. In this case, it is recommended to prescribe complex therapy using BTA and fillers, which compensate for tissue depression in the commissure area of ​​the lips and allow smoothing out “marionette” wrinkles running from the corners of the mouth to the chin.

Safety Concerns: If you use too much BTA and/or inject close to the corners of the mouth, the effects of the toxin may spread to the levator muscles. As a result, adverse effects such as drooling, speech impairment, or mouth asymmetry may occur. Therefore, it is necessary to begin therapy with a shallow injection of small doses of the drug, placing the injection points at a sufficient distance from the corners of the mouth.

Gummy smile

In the literature, a gingival-exposing smile is defined as excessive (more than 2 mm) display of gingiva when smiling. This is a fairly common problem.

Some experts believe that a gummy smile is caused by the joint work of several facial muscles: the levator labii superioris and ala nasi, the levator labii superioris and the zygomaticus minor. Other authors believe that the orbicularis oris muscle and the depressor septum muscle are involved in the formation of a gingival smile. Finally, some experts link a gummy smile to the activity of the levator labii superioris muscle, emphasizing that this muscle is the only one that should be affected.

In addition to botulinum therapy, there are alternative correction methods that provide permanent results, but they are more invasive. For example, myotomy of the levator labii superioris muscle results in repositioning of the upper lip, while frenectomy involves removal of the frenulum of the upper lip. Subperiosteal dissection of the gingival mucosa in the upper jaw in combination with orthognathic surgery and subcutaneous dissection are also surgical methods for correcting a gummy smile.

In terms of non-surgical methods for correcting this type of unaesthetic smile, the injection of botulinum toxin into the levator labii nasi muscle, which is considered the main culprit, has proven effective. As long as injection technique is strictly followed, the results of this simple method are excellent and the risk of complications is low.

Safety considerations: The injection points into the levator labii superioris and ala nasi muscles should not be too low. Otherwise, there is a risk of an asymmetrical smile as a result of diffusion of botulinum toxin into the orbicularis oris muscle. Diffusion has a positive effect when the muscle is at rest, but also leads to an asymmetrical smile.

Lumpy chin (orange peel effect)

Dimples on the chin are formed as a result of contraction of the mentalis muscle. BTA injections can make your chin smoother. However, optimal results are achieved with combination therapy, including injection plastic surgery.

Safety Concerns: Injecting more than the recommended dose or injecting too close to the lower lip may impair the function of the depressor labii inferioris and orbicularis oris muscles, causing drooling, articulation problems, oral asymmetry, and ptosis of the lower lip. To avoid adverse events, you should adhere to the recommended doses and points of administration.​

This article is part of the special project Injection anti-aging

You can read all the articles on this topic:

SPECIAL PROJECT. And injectable anti-aging

Literature:

Alexander Borodko , plastic surgeon, full member of the All-Ukrainian Society of Plastic, Reconstructive and Aesthetic Surgeons (Ukraine)

Les Nouvelles Esthetiques 2015/№1