"Red flags" for botulinum therapy

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

The Ukrainian community of aesthetic medicine doctors has traditionally been a leader in the implementation of innovations; we have been widely using botulinum toxins in the so-called off-label zones for more than 15 years, we have a huge number of publications of various proprietary techniques. The specific mentality of our patients, our doctors, and, to be honest, the wide holes in our legislation still allow us to feel quite free in the field of innovation.

The American Society of Plastic Surgeons has published data that since 2000, the number of procedures using botulinum toxin has increased by 750%; moreover, the procedure has become much younger: in 2015 alone, the proportion of patients under the age of 30 increased by 64%.

The official indications for the use of botulinum toxins have also expanded significantly: even in such a conservative society due to strict requirements as the United States, the procedure is finally officially approved and a recommended protocol for the correction of crow's feet has been developed, not to mention completely new horizons in other areas of medicine ⎼ for example, for the treatment of chronic migraine, tension.

Nevertheless, I have developed a number of restrictions for myself that I try not to violate. They are not considered official contraindications; there are official instructions for the drug for this purpose. These are my personal stop signs , the signs of which make the patient refuse to undergo this procedure, since the risk of complications or an extremely unsatisfactory aesthetic result significantly outweighs the possible advantages. Fortunately, the current field of aesthetic medicine has a sufficient number of alternative paths.

Red Flag #1

The first stop sign is for patients with significantly reduced skin elasticity, or hyperelastosis .

Characteristic markers are the pronounced effort that these patients make in order to perform regular functions ⎼ for example, maintaining an open gaze. As a result of such “hyperefforts,” these patients develop pronounced, increased wrinkles, often even at the age of 30–40 years.

Professor Belousov has an interesting article “Formula of facial tissues and its use in plastic surgery”, published in the journal “Aesthetic Medicine” back in 2006, dedicated to assessing the condition of the skin and making it possible to assess the prognosis of the effectiveness of a facelift in patients of the same age group, but with different skin type. Absolutely the same rules apply to botulinum toxin.

Photo 1 shows the classics of hyperelastosis: dense, completely inelastic skin, severe disruption of the blood supply to the dermal layer, a large number of deep wrinkles and furrows. This patient achieved a good aesthetic result using Lip & Eyelid Formula phenol peeling. (Fig. 1).

Photo 1. Hyperelastosis. Patient before and 14 days after using Lip & Eyelid Formula

Red flag #2

The second marker of a patient’s refusal to undergo a botulinum toxin procedure is signs of significant disruption of the drainage function of tissues , that is, when we see that turning off any muscle group will lead to a significant disruption of lymphatic drainage .

In the vast majority of cases, this problem is combined with severe somatic pathology, sometimes in a compensated form (for example, stage 2⎼3 hypertension). I am always concerned about the use of ACE inhibitors by patients. According to my observations, most of them cause pronounced lymphostasis; moreover, the likelihood of getting angioedema when injected with HA fillers increases significantly. This, in turn, is fraught with complications in therapy, since the bradykinin-kinin system does not respond to the removal of edema with corticosteroids and antihistamines, unlike edema caused by the kallikrein-kinin system (according to our colleague M.A. Krasnoselskikh, angioedema is quite well can be relieved with aspirin or aspirin-cardio; for patients who initially worry him about their pronounced pastiness, he recommends a preventive preparatory course). Thus, I am always alarmed by the patient’s general pastiness and tendency to edema in the morning, and the question of what medications the patient is taking is mandatory. In general, it should be remembered that after 35 years, due to age-related anatomical changes, the role of the drainage function of the lower lateral part of the m. orbicularis oculi. Strictly speaking, this portion of the muscle is the only “elevator” upward in the near-orbital zone, and turning it off is simply unreasonable. When correcting crow's feet, I prefer not to go beyond the line of the outer canthus of the eye. Violation of this rule leads to a high risk of complications of lymphostasis and even a higher risk of getting an unfavorable aesthetic result, since the cheek-zygomatic packets and fat packets as a result of such a blockade move down, and the wrinkles of the lower eyelid shift at the root of the nose.

If there is even a slight threat of impaired pumping muscle function, we refuse botulinum toxin in favor of HA fillers, threads, phenol peels, and surgical tightening.

Photos 2 and 3 show the classics of such cases:

The first patient has severe pastosity, hypertension and a history of taking ACE inhibitors . Additional “complicating factors” are facial features: the tail of the eyebrow extends onto the temporal fossa, ⎼ thus, botulinum toxin is simply unable to raise the eyebrow; blepharochalasis of the upper and lower eyelids guarantees maximum problems if botulinum toxin is used in the periorbital zone (Fig. 2).

Photo 2. Pasty patient, hypersthenic type of build

The second patient is also characterized by severe pastosity, a hypersthenic type of structure, there is a hernia of the lower eyelid, a narrow forehead and the location of the eyebrow tail on the temporal fossa, a heavy middle third . All this speaks in favor of refusing to use botulinum toxin due to its low effectiveness in this particular case. (Fig. 3)

Photo 3. Pasty, hypersthenic type of build. Narrow forehead, lower eyelid hernia, severe middle third

Red Flag No. 3

This includes patients with severe tissue ptosis, hypersthenic body type, severe tissue excess, especially in combination with reduced skin elasticity .

The classic method for identifying such excess skin on the lower eyelid remains the pinch test: normally, the folded skin of the lower eyelid should completely straighten out in 2-3 seconds. The simplest marker of excess skin in the upper third of the face is leaving folds and wrinkles alone. Heavy hypertrophied soft tissues of the lower third will also lead to the ineffectiveness of facial oval correction with botulinum toxin, that is, the “Nefertiti method” (Philippe Levy method) will not work, which will lead to dissatisfaction with the patient’s expectations.

Photo 4 shows a patient with reduced tissue elasticity and pronounced excess soft tissue . A clear aesthetic result could not be achieved using botulinum toxin in any case; perhaps a combination of thread techniques, HA fillers or autologous fat and deep peeling would be more effective. However, the patient really appreciated the set of measures proposed to her and preferred plastic surgery. (Figure 4)

Photo 4. Reduced elasticity in combination with excess soft tissue, before and after plastic surgery

First published: Les Nouvelles Esthetiques Ukraine 4 (98)/2016