List of contributors

It is an honor and a pleasure to write a Foreword for the new edition of Dr. Benedetto’s book Botulinum Toxins in Clinical Aesthetic Practice. The first edition of this book, under the title Botulinum Toxin in Clinical Dermatology was very well received and much admired. However, time has moved on and it is time to update the information which was available in the earlier book. The amount of information about the botulinum neurotoxins and especially about their cosmetic use has increased dramatically in the last few years with new papers being published daily. It is important to have a synthesis of this new information and its integration into the previously available knowledge. In addition, the range of individuals who are administering the toxin has increased significantly. Hence the new edition of this book.

I have particularly appreciated Dr. Benedetto’s selection of his coauthors; each is an acknowledged expert in the area in which they are writing. Dr. Benedetto has written many of the “core” chapters himself but has called on the assistance of other experts in important topics such as cosmetic indications which are less used in North America. Readers will be delighted by the clear anatomic diagrams and appreciative of the clear advice on the handling and dilution of the currently available toxins—subjects which have caused much confusion.

Dr. Benedetto is a well-known expert in both dermatology and aesthetic medicine. His especial area of expertise is the surgical or procedural side of dermatology and he has spent many years perfecting skin cancer treatment techniques and treating many thousands of skin cancer patients successfully. However, he has also achieved a deserved reputation in the cosmetic world, especially in the use of botulinum toxin. For many years he has been interested in the application of botulinum toxin, not just to the upper face but also to the lower face and especially in individuals with facial asymmetry.

This elegant book is appropriate for all who are interested in this field of knowledge. It will be appreciated not only by health care workers who administer the toxin but also by those who enjoy its beneficial effects. The former will improve their skill in the use of the material and the latter will learn more about how botulinum toxin can be used for good. I encourage all of you who are interested in this topic to read this excellent book.

Alastair Carruthers

Vancouver, Canada

September 2010

Just a few short years ago the compilation of different injection techniques for the cosmetic use of the then-available botulinum neurotoxins (BoNTs), namely BOTOX® Cosmetic and Myobloc™/ Neurobloc™, appeared to be a daunting undertaking. Because of the exponential developments in the clinical use of botulinum toxin A (BoNTA), this second edition quickly became a foregone conclusion. Maintaining the original mission of an instructional manual, this updated edition attempts to record the improvements that naturally have evolved from earlier injection techniques. It also introduces newer and innovative ways to utilize the different BoNTs that are presently available worldwide.

In the United States, the glabella remains the only area of the face that is approved by the FDA for the cosmetic use of BOTOX® Cosmetic, now identified by its nonproprietary name of onabotulinumtoxinA. Consequently, except for the glabella, all the cosmetic injection techniques described in this edition, as in the previous one, apply to nonapproved, off-label indications, which makes this book unlike most other textbooks in medicine.

It is sobering to realize that throughout human existence men as well as women have always sought ways to improve their appearance. Dr. Caroline Koblenzer takes us through a historical interpretation of beauty and the beautiful and how the use of BoNT can supplement our patients’ incessant attempts to maintain the appearance of youthfulness. Faced with an overwhelming amount of new scientific and technical information, Dr. Roger Aoki updates us with some of the latest developments in the pharmacology and immunology of BoNTs.

Understanding functional anatomy cannot be over emphasized and Dr. James Spencer has made a concerted effort to apply his knowledge of anatomy in a meaningful and practical way as it relates to the use of BoNTs. The nuclear chapters on treating the face, neck, and chest with injections of BoNTA have been reorganized and expanded, assimilating a number of improved injection techniques with the plethora of recently published clinical articles.

Dr. Woffles Wu, one of the early initiators of the intradermal use of BoNTA, has complemented this edition with his innovative techniques of muscle contouring and skin redraping. Reducing muscle bulk and girth of various parts of the body are techniques that are frequently

practiced in the East and are quickly becoming popular in the West. Dr. Kevin Smith continues to impress us with avant-garde uses of BoNTA for treating Raynaud’s phenomenon and other painful conditions and scars as well as describing potential techniques for lifting the female breasts with injections of BoNTA. He also presents some tips on the management of an acute overdose of BoNTA.

OnabotulinumtoxinA (BOTOX® Cosmetic) is no longer the only BoNTA approved in the United States. As anticipated in the first edition, DYSPORTTM (abobotulinumtoxinA) finally made its debut in the U.S. market about a year ago. Dr. Gary Monheit, who headed the U.S. clinical trials for onabotulinumtoxinA, has updated the injection techniques for its clinical use. He also previews the pharmacology of the noncomplexed (naked) BoNTAs and introduces incobotulinumtoxinA, a “naked” BoNTA currently used in Europe, Mexico, and South America and soon to be introduced into the U.S. market. He also gives us a peek into the future with as much information currently permissible about a topical BoNTA presently undergoing phase II and III clinical investigation. The chapter on BoNTB (rimabotulinumtoxinB), the only nontype A neurotoxin approved by the FDA, has been updated by Dr. Neil Sadick. Dr. Dee Anna Glaser, current President and Founding Member of the International Hyperhidrosis Society, has revised and updated the chapter on hyperhidrosis.

Another enhancement to this edition is Dr. David Goldberg’s expert rendition of medicolegal considerations for those physicians who treat patients for cosmetic purposes. This important aspect of medical practice rarely is addressed, but there are pertinent issues of which we should be aware.

Particular recognition and a special expression of gratitude is due to Lisa Van Horn for her organizational skills and secretarial expertise that facilitated the completion of this book. Finally, we are all indebted to those physicians who have treated and continue to care for patients with BoNTs for therapeutic and cosmetic purposes. Their commitment to the improvement of their patients through the advancement of sound and effective medical care should be lauded and emulated.

Anthony V. Benedetto DO FACP

September 2010

INTRODUCTION

Why, one may ask, in a social climate where poverty is rife and the delivery of basic health care, if not absent, certainly unevenly distributed, why is the search for what is perceived as physical beauty still so much a part of the lives of so many? This question has generated considerable sociologic research (1–4), and that it is indeed the case, is demonstrated by the nearly $12 billion that was spent on cosmetic procedures in 2008 alone (5). In order for us to appreciate the reasons for this vast expenditure, it is important for us to understand that inherently there is, at any given time, a “consensual view,” a stereotype, of what constitutes beauty (1–4), and how, if one is to be successful in life, it is important that one do one’s best to conform to that stereotype for a number of very important and indeed realistic reasons.

In what follows, we will consider the ways in which the consensual view of beauty in Western civilizations, and most particularly in North America, has changed over the centuries. This in contrast to the Orient where traditional esthetics remained firmly in place until Western influences were introduced. How the view has changed for both men and women, and some of the forces that have led to those changes will also be considered, while in order to understand better the ongoing need to try to conform to the prevailing stereotype, the psychological development of the body image, and how the way one feels about oneself and about that image impact one’s performance in every sphere of life, will also be described. Finally, aspects of the current stereotype and what forces are at work to determine its form will be discussed, as will the impact on the psychosocial well-being of the individual, when attempts are made to achieve the stereotype.

THE CONSENSUAL VIEW OF BEAUTY

As noted, there is generally held to be a consensual agreement within a given culture as to what features are deemed beautiful, though clearly there is great variability between cultures as to what particular characteristics are desired (4). One certainly might wonder how such a consensual decision could be arrived at, and indeed studies are under way to determine which parts of the brain are activated, and what affective stimuli are involved, when the level of beauty of a given face is under consideration (6,7). Western literature is replete with discussion as to whether or not physical beauty equates to moral goodness and whether it necessarily parallels physical health (1,8). To some, it is merely a “new indicator of social worth” (8), and, indeed, historically it appears that there has been a “trickle-down” effect, as concepts of beauty espoused by the rich have passed down through the socioeconomic levels to become more widely held (9).

An anthropologic view is that we are—unconsciously, one would presume—intent only on procreation and thus we find attractive those features that would point to procreation as a possibility (3,6,10–12). These features have been characterized as symmetry of face and body, full lips, smooth clear skin, clear eyes, lustrous hair, good muscle tone, animated facial expression, and a high energy level—features that one would intuitively associate with good health, certainly, although studies suggest that these features are not necessarily associated with fertility (10–14).

But one need only look at art through the ages to see that this particular stereotype has not always been sought, and that the consensual

view of beauty has changed back and forth over time, as has been well-summarized in the literature (3,10,14). In the Middle Ages, for example, Western feminine beauty was portrayed as fragile and ethereal—a reflection, perhaps, of the veneration of women that was characterized in tales of chivalry—while later, in the sixteenth and seventeenth centuries, beautiful women were portrayed as much more robust. By the eighteenth century, fragility had returned, and in the early part of the nineteenth century, the frail, pale willowy woman was once again regarded as the beauty ideal, an ideal that it is suggested was consonant with the puritanical prudishness of the time. Later, in the latter part of the century, a much more robust, heavier-set woman emerged as a beauty, reflecting the fact that times had become economically easier, and the middle classes were more financially secure. This more heavy-set, robust style of femininity was in turn superseded by a muscular, athletic-looking woman, as sports began to be introduced on college campuses, and women started to take a more active part in the working world (3,10).

Just as in women, the consensual view of beauty in men has also changed over the years. In the mid-1800s the male ideal was pale and thin, “dyspeptic men, the puny forms, and the bloodless cheeks” due perhaps to lack of exercise and the “prevailing air of serious business.” It was stated at the time that “a straight back and a well-carried chest” meant that a man was either a “soldier or a foreigner” (15). Lord Byron’s look was that most admired, with “chiseled features, great fineness and silkiness of the hair, and tapering extremities,” and indeed, Byron reputedly was wont to subject himself to diet regimens to maintain that look, perhaps an early—and indeed male—example of body dysmorphic issues and anorexia, problems that, particularly in young women, are very much with us today. Prince Albert, the Prince Consort, was slender and with fine features, and of course Napoleon, another admired character, was short (16).

In the latter part of the nineteenth century, this somewhat esthetic concept of beauty was reversed completely as European immigrants to America brought with them traditions of physical exercise and dedication to outdoor sports. Andrew Jackson, the frontiersman, assumed the presidency, and the “trickle-down effect” on taste was clear, as men, eager to display their financial prosperity, showed off their rubicund faces and protruberant abdomens (19). By the early 1900s, this again had changed, and the new image of youthful masculinity and beauty was a tall and athletic figure, with fine features (16–18).

Though cosmetics had been associated initially with royalty and the aristocracy, and later with prostitution and the theater, even two hundred years ago many ordinary women lightened their complexions by ingesting or applying arsenic in addition to guarding their skin from sunlight. By then cosmetic manufacturers were advertising more extensively, and the more widespread use of their products was justified by such terms as “elegant,”“stunning,” and “chic” (19).

THE CURRENT CONSENSUAL VIEW

More than any prior generation, our current consensual beauty ideal of both face and body, male and female, is generated to a large extent by our exposure to omnipresent advertising by the cosmetic, fashion and media industries, and most recently by some of our colleagues. This advertising may be in print, on-line, or on the air, but it constantly

reminds us that we may be falling short, in one way or another (8,20–27). Today’s ideal for women is young, very slender and clad in the fashions sported by the models and media idols whom we see, whether or not we choose, several times each day. Her complexion is smooth and beautifully enhanced by the clever application of cosmetics (28), her hair glistening, and her muscles toned. Yet, interestingly in one study, when questioned, young women found those faces that most approximated the mean, rather than the ideal, to be the most attractive (22). For men, though still young and slim, the ideal handsome male has defined clean-cut masculine features, and most importantly, slender bodies with well-defined muscles (1). In both sexes, as the individual progresses through the different phases of life, from childhood to old age, these concepts of beauty and how that person perceives himself or herself in relation to the prevailing concepts remain crucial, and the goal for the emotionally healthy is still to strive to meet them. In both, symmetry is important and in both, youth is of the essence (1,3,12,28–30).

In either case, as Hilhorst notes, beauty can be achieved by “cultural means” and thus it expresses both our present culture, and our personal choices (2,3). These choices, in turn, are determined by the way in which we perceive ourselves, how we feel about that perception, and how we compare it with others. In other words, despite the fact that our choices are strongly influenced by the prevailing ideal, choices about the way we display ourselves are made fundamentally on the basis of our body-image and our self-esteem—two aspects of the self that are integral to the personality at every phase of life (2,31–35).

Body Image and Self-esteem

What we understand by “body-image” is complex and multidimensional. It is not only “the picture of our own body that we form in our own mind” (32), but also the way that we feel about ourselves. Having both physical and psychologic components, body-image is intimately associated with self-esteem. Clearly this complex is of some importance, since the way in which we see ourselves, whether it pleases us or whether we see deficiencies, affects every aspect of our lives—our thoughts, our emotions, and our relationships (31).

Development of Body Image and Self-esteem

One may wonder why it is that for one person even a minor flaw in appearance is devastating, while for another that flaw, or even greater disfigurements, may be of no consequence whatsoever. Infant observation studies have shown that these very different feelings about oneself have their beginnings during one’s very early life experience, and evolve in the context of one’s earliest relationships (35).

The emotional environment for the infant is contained within the relationship between the infant and the primary caretaker. In the reciprocal interaction that takes place between the two, if tactile stimulation is congruent with the infant’s needs, and the environment accepting, the infant will begin to incorporate and make a part of himself or herself both a capacity to modulate anxiety, and an understanding of the boundaries between the self and the other, with an appreciation of his or her own size, shape, and physical configuration. The quality and the amount of empathic touching that takes place within this fundamental relationship will help to determine the integrity of the body image, how close it is to reality, and whether the feelings about the self that are generated, are positive or negative. When the caretaker is in tune with the infant’s feelings, expressing love and admiration in smile and touch, the body-image will be stable, the boundaries firm, the self-esteem positive, and the individual confident and secure (33,34). The inner feelings aroused in this early stage of development are reinforced by parental attitudes as the child grows. Parental values and expectations with regard to looks and behaviors—what is perceived as beautiful or good—are transmitted verbally and nonverbally to the child, and

whether these parental attitudes are overtly met with cooperation or with opposition, at some level most children wish to grow up to be like the parents, and to please them and make them proud. However, the reverse is also true—when demanding, perfectionistic, and rigid parents have expectations that are unrealistic, the inevitable parental disappointment or dissatisfaction is, in like fashion, internalized by the child, becoming a part of the self, and impacting the body-image and the quality of self-esteem (34). Feelings of guilt arise, and dissatisfaction with different aspects of the self may later lead to anxiety or depression, and to disquieting issues about lack of goodness or beauty, with feelings of ugliness associated with a poor personal presentation.

Progressing into adolescence, the child must separate emotionally from the parents in order to develop an individual identity. Aspects of the parents that the child admires will be incorporated and integrated into the personality, but as the child separates, it is peers, father-figures or sports idols who become the ones to emulate in looks, dress, and the ideals of masculinity for boys. Indeed the boy may try out many styles, perhaps carried to extremes—for example body piercing, tattoos, etc.—before arriving at his own comfortable identity. For the girl the task is more difficult, as she is still under great pressure to please the mother and to incorporate admired maternal traits. She too must struggle to separate, and at the same time emulate in attitude and style, the peers, models and media idols that she so admires. For both boys and girls acceptance by the peer group, and the “sameness” as peers, are of paramount importance for emotional well-being (31,32).

As the adolescent matures, the body-image and self-esteem become established as psychological entities, and come to settle at some point along the broad spectrum of affects, from positive to negative. In adult life, social interaction and appearance-related feedback serve to reinforce, or exaggerate the individual’s feelings about the internalized persona, whether those feelings be positive or negative (37). It is important to note that the powerful impact of the media on those feelings, cannot be overestimated (3,20–25).

WHY AIM TO EMULATE THE IDEAL?

And so what are the advantages of emulating the current cultural ideal of beauty, in so far as one is able? Those who most closely approximate the ideal, although they may serve as objects of comparison for the less well-favored, generating envy, nevertheless have enormous personal, social, and professional advantages, as many studies have shown. A small sampling will serve to illustrate this point.

In terms of subjective experience, physically attractive people reportedly receive more social reinforcement, have closer relationships, and experience greater intimacy and greater satisfaction in their sexual interactions than do those less favored (38,39). Objectively, examples of the benefits of conforming to the current consensual ideal of beauty can be found in essentially every aspect of life. Pretty children, for example, get better grades than those perceived as plain; plain children attract greater antipathy from their fathers (40); pretty waitresses get better tips (41); physically attractive men and women are more readily hired, receive earlier promotions, and make more money than do those who less clearly approximate the current consensual ideal (2,42); while women tend to marry those of equivalent good looks, so that the beautiful woman is more likely to get the handsome husband (43). It may also be that those who are physically and attractively well-endowed bring out good qualities in others; for example in one study, when a man believed himself to be speaking to a beautiful woman by telephone, he was found to make conversation that was significantly more interesting than in the obverse (44).

It is important for us to remember that the media images that we cannot avoid, and that reflect our current consensus of what is beautiful, are not wholly realistic, as they have been touched-up, air-brushed, and enhanced in a number of ways (42). But it is plain that ours is a

culture of youth, and as the population ages, and as economic conditions deteriorate, men and women are tending to work longer, and to retire at a greater age, thus increasing competition in the workplace. In order to remain competitive, men like women are struggling to look younger, healthier, more physically active, and more consonant with the current ideal of masculine good looks. Thus both men and women are seeking cosmetic improvement in greater numbers than ever before (3,5,8,21,26,42,45–47).

Clearly we are not dealing in absolutes, and as noted earlier, there is a broad spectrum that encompasses the different levels of emotional health that we encounter in practice (31,35,46–48) At one end of the spectrum is the successful individual who has a generally positive selfesteem, but who may have physical features that for one reason or another, he/she may want to change a little, or make more youthful. Such an individual will have goals that are realistic, and is likely to be satisfied by the results of any procedure that is undertaken.

The narcissistic individual may have an entirely realistic view of his or her appearance, but yet may find it imperfect for one or another reason, and seeking perfection, may demand procedures that will not satisfy, because, of course, that individual’s view of perfection may not be attainable (49).

At the other end of the spectrum is the unfortunate person for whom early life experience has led to a negative and insecure body-image with boundaries that are not firm, poor self-esteem, and a depressive affect (33,34). This person makes constant negative comparison with others, both anticipating and attracting negative social feedback in a way that generates a destructive emotional downward spiral. For this person, social situations become progressively more uncomfortable, intimacy is to be avoided, and survival in the workplace may be threatened. Such a person, in defense against these depressive feelings of hopelessness, may deride those who seek ways to improve themselves. Alternatively, such a person may seek ever more radical interventions—surgical or nonsurgical—to improve the real or less-real perceived deficits in face or body configuration that have come to dominate that person’s life (48).

Body dysmorphic disorder is the name given to the condition in which there is no abnormality, or a very minor abnormality, that is perceived by the individual in a negative way, which is out of proportion to the reality. The perception of abnormality may be relatively mild or of frankly delusional proportions and may lead the individual to engage in behaviors that are self-destructive (42,47,48). These are the patients who may have anorexia or bulimia, or who may demand ever more radical surgical interventions from the cosmetic surgeon. It is of critical importance to recognize this syndrome, since nothing that the surgeon undertakes will satisfy, and both suicide of the patient and murder of the surgeon are reported (49–51).

And so, though beauty may indeed be “in the eye of the beholder” (52), should that beholder be the self, looking into the mirror, the search for beauty may become a very important part of that beholder’s life, in ways that will depend on the psychological make-up of that same beholder. Clearly, in some this may be healthier than in others.

In the earlier histories of man, age and the acquired wisdom of the years was respected. Aging Greek philosophers such as Plato and Aristotle, though not young, were valued for their wisdom—indeed there was once the concept that age was beautiful (53). Sadly, during our current generation this view does not hold sway. Youth, and all that youth implies, is the most valuable attribute, and the search for youth— at least as far as looks are concerned—seems to be insatiable. Hence, the rush for botulinum toxin.

Botulinum toxin injections, by eliminating wrinkles, can not only temporarily erase the ravages of time, and create a younger look, but they may also be employed to generate symmetry of face and body (54).

Thus, although there are increasing numbers of medical conditions for which botulinum toxin has been found effective (55–58), if we look back anthropologically, by engendering this symmetry, together with a smooth, clear skin, botulinum toxin can help to create the physical features historically believed to signify fertility—perhaps another of the unconscious motivators in the current botulinum toxin craze (3,6,10–12).

The “trickle-down” wish by the less socially privileged to enjoy the same physical features that characterize those of greater privilege (9) may play a part here also. In our media-driven age, the “privileged”— those of the “rich and famous” media idols, sports figures, and models that we see in so many venues each day—are either very young, or, by dint of hard work, and often at considerable expense, have erased wrinkles, unwanted body weight, and others of the possible signs of aging. Thus it is often the goal of those of us of perhaps lesser “privilege” to emulate that same look in so far as we can, providing yet another force that contributes to the botulinum toxin craze.

Finally, as noted, while medical advances are prolonging healthy life, economic forces are making it necessary for many to work past the usual retirement age. As younger people enter the workforce, their energy and youthful good looks are both psychologically and realistically threatening to those of more advanced age.

And so it is clear that, at this time at least, there are not only deeply entrenched psychological reasons for us to do our best to conform to the current cultural ideal of beauty. Given the realities of our world, and given that our current cultural ideal is one of youth, there are also many very realistic reasons for us to try to emulate that ideal. One way that we can do so—a way that is currently popular for reasons that this book will explain—is by jumping onto the botulinum toxin bandwagon.

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