Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
.pdf
Periocular Applications of Botulinum Toxin 559
Figure 4: Photographs of a patient with horizontal forehead lines before (left) and after (right) botulinum toxin A injection. Upper and lower row photographs demonstrate the static and dynamic wrinkles before and after treatments,respectively. “Star”s in the upper-left photograph, indicate the preferred injection sites for treating forehead lines in most of the cases (doses and sites are customized for each patient). “Arrows” shows the points wher we occasionally prefer to inject to prevent the angry “V” look of the eyebrows
The effect of injections of botulinum toxin in corrugator muscles not only diminish the appearance of glabellar furrows but also broadens the distance between the eyebrows and the eyebrow upper eyelid margin (Figs 3 and 4). By administering 60 U botulinum toxin A injections on glabella and forehead lines, it was observed that frontal muscle activity decreased by 35% in the 2nd week, and aperture between eyebrows increased by 12% when digital photographs were examined.41
In Carruthers, Carruthers and Cohen’s study, a total of 16, 32 and 48 U botulinum toxin A were injected in 8 points of glabella, frontal and orbicularis oculi muscles, the maximum eyebrow elevation was observed in 53% of the
560 Oculoplasty and Reconstructive Surgery
patients in high dose group. No eyebrow or eyelid ptosis was developed in the study. Positive cosmetic effects on such cases have continued even after return of muscle contractions.42
We observe a direct correlation between the dose and treatment of glabellar lines generally, in our practice, but there are studies that show no dose-response relations as well.43
Younger appearance is obtained by increasing vertical aperture of eyelid as seen in the patient in Figure 4, after injections administered in crowsfeet and pretarsal orbicular muscle; however botulinum toxin A injected too close to medial canthus, might induce functional epiphora.44
Eyebrow ptosis and dermatochalasis are frequently seen complications of botulinum toxin. A careful patient selection, low volume/high concentration applications and adding adrenaline in injector in order to decrease complications are recommended.45 Cohen and Dayan also reported that a significant correction was obtained in dermatochalasis in 47% of the patients by means of infiltrating botulinum toxin into orbicularis and corrugator muscles in order to decrease dermatochalasis.46
Forehead
Frontalis muscles lies vertically between the orbicularis oculi muscle and inserts widely into the galea on each side of the forehead and causes the horizontal forehead rhytides when contracted.47-48 To decrease the contraction effect, we inject the thickest portions of the muscle at 4-8 points on each side, points 1-1.5 cm apart. Doses between 0.5 and 4 U botulinum toxin A at each point is, generally injected in accordance with the severity of the wrinkles. It is recommended to laterally raise the line of the injections away from the brow to prevent lateral brow droop, however we prefer to inject that area not infrequently to prevent the “joker” look (Fig. 4).
Periocular Applications of Botulinum Toxin 561
Crowsfeet and Palpebrae
Orbicularis oculi muscle lies subdermally in a circular fashion surrounding the palpebral aperture and its main function is closing the eye. This muscle also contributes highly to the lacrimal pump mechanism in drainage of the tears down the nasolacrimal duct to the nasal cavity. Temporal injections subcutaneously target the orbicularis oculi fibers, especially causing the crawsfeet rhytides which are one of the first signs of aging.
In Figures 5 and 6 photographs of patients treated for crawsfeet wrinkles before and after botulinum toxin A injection are seen.
Injections in the upper temporal part of the orbital fibers of orbicularis oculi muscle lift the lateral end of the eyebrow and decrease the dermatochalasis at this area.45-46,48
Injecting 1-3 U of botulinum toxin A in the subciliary pretarsal fibers of orbicularis oculi muscles we can flatten the hypertropied orbicularis muscle which is not so infrequently confused with lower eyelid bagginess. This application must be done cautiously may lead to lower skleral show and occasional epiphora when the doses are exceeded.
Figure 6 also shows the patient flattened hypertrophic pretarsal orbicularis before and after botulinum toxin A injection.
Injections of 1-5 U botulinum toxin A at each point, at least 1 cm lateral to the orbital rim avoid the diffusion of the toxin to the extraocular muscles, thus complications like diplopia. Injecting too close to the lid margins may lead to insufficent eyelid closure, reflex tearing and sometimes corneal erosions. It was reported that botulinum toxin leaking into extraocular muscles might induce dyplopia,49 and it might also cause decrease of lacrimal excretion, corneal ulcers and decrease in visual accuity due to high doses of botulinum
562 Oculoplasty and Reconstructive Surgery
Figure 5: Photographs of a patient with crawsfeet before (left) and after (right) botulinum toxin A injection. Upper and lower row photographs demonstrate the static and dynamic wrinkles before and after treatments,respectively. “Star”s in the upper-left photograph, indicate the preferred injection sites for treating crawsfeet in most of the cases (doses and sites are customized for each patient). Note that the lateral eyebrow is also lifted and increased the distance between the lateral canthus and the tip of the eyebrow
toxin injections diffused in posterior septum, and infiltrating in lacrimal gland.50 Another paradoxical recommendation for botulinum toxin procedures is inducing pretarsal orbicular muscle weakness to decrease lacrimal drainage effect, which is considered as a complication of botulinum toxin , therefore can be used for recovery of dry eye.51
These points must be kept in mind when injecting the orbicularis oculi muscles.
General and ocular complications are shown in Table 5. In addition to the complications given in Table 5, perilabial ptosis when botulinum toxin is injected for crowsfeet
Periocular Applications of Botulinum Toxin 563
Figure 6: Photographs of a patient with crawsfeet and lower hypertrophic orbicularis muscle before (left) and after (right) botulinum toxin A injection. Upper and lower row photographs demonstrate the static and dynamic wrinkles before and after treatments,respectively. “Star”s in the upperleft photograph, indicate the preferred injection sites for treating crawsfeet and lower hypertrophic orbicularis muscle in most of the cases (doses and sites are customized for each patient). Note that the lateral eyebrow is also lifted and increased the distance between the lateral canthus and the tip of the eyebrow. Lower pretarsal fibers of orbicularis oculi muscle is flattened (upper and lower right)
treatment occurring due to zigomaticus major muscle being affected is a rarely observed complication, which requires special care.52 Festoon formation developing in recovered cases with blepharoplasty is another reported botulinum toxin complication. The reason is decreased lymphatic drainage due to hypotony of orbicular muscles of the patients involved, and fluid accumulation in loose soft tissue on zigoma.53
Another complication that could be caused by anticholinergic effects of botulinum toxin is high intraocular pressure
564 Oculoplasty and Reconstructive Surgery
Table 5: Complications of botulinum toxin in periocular procedures
General complications
•Pain,
•Ecchymosis, rash, hematoma
•Headache
•Flu-like symptoms,
•Nausea, dizziness
Ocular complications
•Undercorrection
•Asymmetrical features
•Change in and/or loss of facial expression (overcorrection)
•Lower eyelid laxity
•Dermatochalasis
•Ectropion
•Epiphora
•Eyebrow and eyelid ptosis
•Lagophthalmus in closing due orbicularis muscle weakness
•Keratitis sicca
•Dyplopia
•Photophobia
•Decrease in visual accuity
•High intraocular pressure?54
due to possible angle closure occurring as a result of anticholinergic effects when reaced to ciliary ganglion.54
Other applications of botulinum toxin that can be adjuncts to the periocular applications in this chapter are listed in Table 6.
Extensive use of botulinum toxin for as an adjunct to CO2 laser cosmetic surgery and non-surgical procedures are reported.55 Dehiscence and scar formation was observed less in patients who were injected with botulinum toxin in order to limit the movement of the surgically interfered area when compared to patients not treated with injection.56
Periocular Applications of Botulinum Toxin 565
Figure 7: Patient with lagophthalmus (upper) had ptosis complication (middle) after botulinum toxin injections and returned to normal after 4 weeks with the correction of lagophtalmos (lower)
566 Oculoplasty and Reconstructive Surgery
Figure 8: Patient with lagophthalmus (upper) who had good closure of upper eyelid (middle) had insufficient eyelid closure complication (lower) after botulinum toxin injections, due to diffusion of the toxin into orbicularis oculi muscle
Periocular Applications of Botulinum Toxin 567
Table 6: Other therapeutic and cosmetic applications of botulinum toxin
•Nose wrinkles (bunny lines)
•Perilabial wrinkles
•Low lip corners
•Orange peel look on the chin
•Platismal bands
•Horizontal neck wrinkles
•Décolletage wrinkles
•Rhinoplasty
•Scar revision
•Adjunct procedures for other anti-aging methods and surgery
Table 7: Contraindications of botulinum toxin injections
•Pregnantcy and lactation
•Neuromuscular junction disorders (Myasthenia gravis)
•Peripheral motor neuropathies
•Active infection
•Hypersensitivity to any of the contents
Botulinum Toxin, Botulismus and Antibody Development, and Non-responder Cases
As the doses are low and intervals are relatively long in cosmetic procedures, there is only one reported case in the literature who was reported for botulismus development after injection, and this 47-year old female patient was completely cured, despite a long-term healing period.57
One of the most important issues to be faced in relation with increasing number of cosmetic procedures in the future is antibody development against botulinum toxin, and the concern for not receiving proper response after the treatment.58 For cases refractory to botulinum toxin A injections,
568 Oculoplasty and Reconstructive Surgery
other botulinum toxin subtypes might receive responses.59-61 However, pharmacological effects and duration of activity of such various subtypes are different from botulinum toxin A, and Botox and Dysport are still considered as the most effective and reliable preparations.62
Cross tolerance may occur between various subtypes of the toxin. In a study published by Berwick et al, it was reported an 8-year old child who did not respond to the treatment after receiving botulinum toxin B injections three times in salivary glands. He also became refractory against botulinum toxin A preparations. His botulinum toxin A antibody titration was 0; this situation induced an idea that botulinum toxin B antibodies engaged in a cross-reaction with botulinum toxin A molecules, and a clinical response was prevented as these complexes were destroyed by phagocytes.63
Dutton found in his meta-analysis study in 1996 that 6% of the cases did not respond although this was the first injection of botulinum toxin A.64 Unlike these cases, patients who responded when the dose was increased or who did not respond though they did to former treatments develop secondary antibodies and neutralized botulinum toxin molecules. This phenomenon should not be confused with non-responder cases, and such patients can be treated with different botulinum toxin subtypes.65
QUESTIONABLE ISSUES ABOUT DILUTION AND STORAGE?
According to recommendations of producer companies, one of the paradoxical issues about botulinum toxin is, the toxin’s activity decreases significantly within a certain period after reconstitution, and breaks into pieces due to fracture of protein