ABOUT CASE 2
From the Files of Michael H. Gold, MD, FAAD
A 60-year-old white female wanted treatment for her glabellar, forehead, and lateral canthal lines. The patient stated that she was interested only in a BTXA injection and did not desire treatment with any energy-based devices or fillers.
AboBTXA was used. A total of 85 U was delivered using a 30G needle: 10 U into each of 5 sites for the glabellar complex; 5 U into each of 4 frontalis sites, and 2.5 U into 3 sites on each side of the face (crow’s feet and lateral brow) (Figure 3A). Alternative treatments would be 32 U of incoBTXA, onaBTXA, or praBTXA, with 20 U/glabellar site in the glabella, 8 U/frontalis site, and 4 U/site in the crow’s feet/lateral canthal lines. Remarkable improvement was seen at 2 weeks posttreatment (Figure 3B).
Dr Gold: Optimal rejuvenation of the aging face often requires multimodal treatment. I complied with this patient’s request to use only BTXA because I sensed she feared cosmetic surgery. I also thought that a good result with BTXA might alleviate her concerns and make her more willing to consider other procedures.
In the United States, only onaBTXA is approved for treating lateral canthal and forehead lines in addition to glabellar lines.1 The other BTXA products might effectively treat lateral canthal and forehead lines, but patients should be told that the treatment is off-label.
Dr Yoelin: Do you perform BTXA injections on the same day as you do another cosmetic procedure?
Dr Cohen: I typically avoid injecting BTXA on the same day that I do procedures that cause a lot of swelling, such as nonablative fractional treatments, chemical peels, full-field laser resurfacing, and fractional ablative resurfacing.
Dr Yoelin: In some patients with horizontal forehead rhytids, frontalis muscle contraction is also compensating for preexisting brow and lid ptosis, which can be unmasked by BTXA treatment of the forehead lines. Preinjection evaluation is important to guide the treatment so that you avoid the situation in which you have addressed one problem but created another.
Dr Cohen: Evaluating patients for brow shape, positioning, symmetry, and dermatochalasis is essential for success with the nuances of treating the upper face. Exercising care with BTXA forehead injections in people with severe upper lid dermatochalasis is especially important because they might be using the frontalis muscle to lift the brow and, in turn, depend on that muscle to lift the lid as well.
Another fine point is that when treating crow’s feet, I often administer the neuromodulator with a medial needle insertion and then lateral advancement of the needle. For this approach, I point the needle toward the temporal hairline at entry and direct it laterally and inferiorly, staying away from the inferior aspect of the orbicularis oculi, which is where the zygomaticus minor inserts. In short, clinicians injecting BTXA must consider where the needle tip ends and not just where it enters.
Dr Kaufman: Lid edema can also occur when treating the upper third of the face. I believe that its cause is decreased fluid movement to the lymphatics as a result of reduced muscle function. The risk for lid edema might be greater when several areas of the upper face are treated at the same time.29