Mauricio de Maio & Berthold Rzany

Botulinum Toxin in Aesthetic Medicine

Editors

B. Rzany

Professor of Dermatology

Clinical Epidemiologist, Division of Evidence Based Medicine (dEBM) Klinik für Dermatologie

CHARITÉ – UNIVERSITÄTSMEDIZIN BERLIN

Charitéplatz 1

10117 Berlin, Germany

M. de Maio

Plastic Surgeon

Faculty of Medicine of the University of São Paulo

Av. Ibirapuera, 2907 – cj. 1202

Moema – São Paulo – SP

CEP: 04029-200, Brazil

Library of Congress Control Number: 2006938423

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Editor: Marion Philipp, Heidelberg, Germany

Desk Editor: Ellen Blasig, Heidelberg, Germany

Cover design: Frido Steinen-Broo, eStudio Calamar, Spain

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Foreword

Botulinumtoxin A in Aesthetic Medicine

Gary D. Monheit, M.D.

Probably the most important event in the evolution of minimally invasive cosmetic procedures is the development of botulinum toxin for cosmetic usage. From a single region and procedure for the treatment of the frown lines over a decade ago, the use of botulinum toxin has evolved into multiple areas, techniques, dosages and now new toxins in this ever expanding field. To capture it all in a comprehensive yet easily read and organized text, Drs de Maio and Rzany have put together this new volume in their approach to facial cosmetics.

This is a welcome addition to their first text on injectable fillers in Aesthetic

Medicine. It is organized in a similar fashion, first giving an overview of the toxin discussing pharmacochemistry, sub-types and products, efficacy, dosage, effectiveness and finally safety. The clinical applications are divided into patient selection, basic requirements and injection techniques. The unique approach of correlating individual anatomic differences in patients as to dosage and injection points with muscle mass gives the clinician a new guide to successful treatment. The technique injection sections discuss all the treatable areas from upper face to lower face and neck, covering anatomy, treatment aims, patient selection, technique, complications and “tips and tricks”.

In this text the clinician will find a wealth of information collected over years of experience by these two renowned aesthetic researchers and clinicians. I highly recommend this text for all aesthetic clinicians from the novice to those with years of experience as the learning curve is applicable for all.

Gary D. Monheit, MD

Clinical Associate Professor

Departments of Ophthalmology and Dermatology

University of Alabama at Birmingham

Dermatology Associates, Ash Place

Suite 202, 2100 16th Avenue South, Birmingham

AL, 35205, USA

Foreword

Christopher Rowland Payne

No cosmetic item has had more impact than botulinum toxin. It is a worldwide phenomenon that has revolutionised cosmetic practice since its introduction 15 years ago. It is almost impossible to find any issue of a women’s magazine from the last ten years which does not include a mention of botulinum toxin. This tsunami of interest amongst the public and amongst physicians has brought forth advances in the way in which botulinum toxin can be used to benefit the face cosmetically. At the crest of this wave of innovation are a number of notable doctors. Amongst this select group are Mauricio de Maio and Berthold Rzany. Their own original work on botulinum has achieved peer admiration around the world. They are known not only for the quality of their scientific papers but also for the clarity of their presentations at scientific and clinical meetings and they each have a huge personal following of loyal patients.

Accordingly, it is absolutely apposite that Mauricio de Maio and Berthold Rzany should be publishing this book now. It is their second book and will bring the practitioner reader right up to date. They discuss the movement away from “more is more” towards “individualisation and the microinjection technique”. The text emphasises clinical method and clearly outlines “how to do it”, making elegant use of half and half (before and after) facial photography of the highest standard. Photographs of this sort require enormous care and patience. Practitioners – and also potential patients – will greatly appreciate these illustrations.

Important discussion points are covered in a ‘questions and answers’ section, including the thorny question of the frequency with which injections need to be repeated. The text, which is fully referenced and, where possible evidence-based, also covers the more advanced and most recent uses of botulinum, including the botulinum face lift, the treatment of facial asymmetry and, of course, safety considerations, contraindications and so on.

This book fully deserves to become the vade mecum of aesthetic botulinum toxin.

Preface

Why another book on botulinum toxin in aesthetic medicine? There are a couple of reasons. First: the main reason is the tremendous progress that we are seeing in the use of this drug, which rapidly outstrips the present literature. Second: we still think there is a need for good books as there is still a lot of confusion and misconceptions around the different indications and the different drugs.

Unlike in the beginning, when botulinum toxin A was used along the principles of ‘the same injection points and doses for everybody’ and ‘bigger doses for bigger effects’ it is now used in a much more differentiated way. Based on the muscular patterns (kinetic, hyperkinetic and hypertonic), we have a much more individualized approach to the treatment of our patients. New indications in the middle and lower third of the face have been added to the well-known areas of the upper face. Multiple facial areas are now treated during one visit, with the aim of global facial rejuvenation with the ultimate aim of the botulinum toxin ‘face lift’. Besides the classic intramuscular injection technique, microinjection techniques are increasingly used. Furthermore, the botulinum toxin world is not a two-product world any more. More and more botulinum toxin products are entering the field to fight for their share in the market.

Based on the views of a plastic surgeon and a dermatologist, this book aims to familiarize the novice as well as skilled user with these new concepts and new preparations to enable both to treat their patients in the best possible way.

This book complements our book on injectable fillers in aesthetic medicine. Like our first book, we have followed an honest ‘how we do it’ approach. As our aim is to improve our teachings we always appreciate direct feedback from our readers, and we encourage you to give us your comments and suggestions for improvement.

Berlin and Sao Paulo, August 2006

Mauricio de Maio Berthold Rzany

Acknowledgments

Neither our first, nor this, our second book, would have been possible without the work of many others. We would therefore like to take the opportunity to thank our patients who helped us get to where we are now, especially those who contributed their photographs to this book. At Springer, we would like to thank Mrs. Marion Philipp and Mrs. Ellen Blasig, and from the German team: Mr. Hendrik Zielke for his help with the content and format, especially for helping us build the chapters on the efficacy and safety of the different botulinum toxin preparations and his ability to cope with all the software, and Mr. Tobias Gottermeier for the excellent photographs and graphic work.

From the Brazilian team: Mrs. Emma Mattos for helping with the updated references of botulinum toxin treatments; Mrs. Liliann Amoroso for working on the photo library which was quite tiring and demanding; and especially the clinical assistants Mrs. Gisele Souza, Mrs. Liliane Carneiro, Mrs. Renata Sanches and Mr. Thais Sorcinelli who have a wonderfully careful way with my patients.