ABOUT CASE 1
From the Files of Joely Kaufman, MD, FAAD
A 41-year-old white female presented complaining about lines between her brows that she believed made her look tired. Evaluation with animation showed depression of the medial brow, which was greater on the right side than on the left, and a U pattern of glabellar contraction, with minimal recruitment of the lateral corrugator (Figure 1A).
A 100-U vial of praBTXA was reconstituted with 2.0 mL of bacteriostatic saline. Using a 32G needle, a total of 25 U was injected at 5 sites: 7.5 U into each medial corrugator, 5 U into the procerus, and 2.5 U into the midfrontalis on each side (Figure 1B). Alternative treatments (total dose administered) would be 75 U of aboBTXA, 32.5 U of incoBTXA, and 25 U of onaBTXA. When the patient returned 10 days postinjection, her glabellar lines were effaced and she had lifting of her medial brows, which helped to open up the eyes so that she looked less tired (Figure 1C).
Dr Kaufman: The patient in this case is relatively young, and her glabellar lines are subtle. Early treatment with BTXA can be very effective for eliminating these lines. BTXA might also help prevent them from becoming deeper and ingrained over time.
In this patient, a 3-point injection technique was used, along with 2 midfrontalis injections to lift the medial brow. I find that aboBTXA might have a larger field of action than the other products, which would make aboBTXA particularly useful for a 3-point injection technique. When I see a patient with little or no use of the lateral portion of the corrugator muscle, I use a 3-point glabellar injection instead of a 5-point injection. This usually keeps the midline arch of the brow intact.
A 5-point injection pattern for treating glabellar lines with equal doses distributed across all sites is recommended by all BTXA manufacturers. This one-size-fits-all approach, however, does not account for interindividual variation in the use of upper face muscles to contract the glabella.
Five different glabellar contraction patterns have been described: converging arrows (Figure 2A), U (Figure 2B), V, omega, and inverted omega (Figure 2C).22,23 Individualizing the injection technique on the basis of the contraction pattern will optimize results.