Botulinum Toxins E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 862

Veröffentlichungsjahr: 2017

Beschreibung

Botulinum Toxins: Cosmetic and Clinical Applications provides a comprehensive and in-depth review of the use of botulinum toxin for aesthetic procedures and medical applications as a stand-alone treatment and as part of combination therapy.

Now a mainstay of cosmetic dermatologic practice, the range of available toxins and their varied applications has grown considerably in recent years requiring the practitioner to carefully consider what approach best suits the needs of their patient. This new book, written by international expert authors, provides guidance to help you refine your technique, add new procedures to your practice, and provide optimal results.

This book:

• Offers guidance on best-practice approaches with botulinum toxin, helping create cutting edge, tailored treatment plans for each patient
• Benefits from a wealth of color images, procedural videos, and expert tips and tricks
• Takes a region oriented approach, providing guidance on treatment of the; glabella, forehead, periocular and perioral areas, and contouring of the lower face and lower leg and calf, and neck rejuvenation
• Contains a thorough review of non-cosmetic treatments such as correction of facial asymmetry, and treatment of axillary hyperhidrosis, plus palm, sole, and craniofacial hyperhidrosis
• Covers exciting new topics, such as future injectables, topical botulinum toxin, and facial contouring including treatment for benign masseter hypertrophy
• Discusses combination therapy of botulinum toxin with other non-surgical procedures such as hyaluronic acid (HA) or filler substances, light and laser sources, and other energy-based therapies
• Includes considerations for darker skin types

Offer your patients the best care, stay on top of cutting edge techniques, and avoid pitfalls with coverage of practical tips and real cases. Botulinum Toxins in Dermatology: Cosmetic and Clinical Applications provides best-practice guidance on the contemporary use of botulinum toxin in isolation and in combination.

Leseprobe

Botulinum Toxins

Cosmetic and Clinical Applications

Edited by

Joel L. Cohen, MD (FAAD, FACMS)

Director AboutSkin Dermatology and DermSurgery Greenwood Village and Lone Tree CO, USA

DavidM. Ozog, MD (FAAD, FACMS)

Chair, Department of Dermatology C.S. Livingood Chair in Dermatology Director of Cosmetic Dermatology Division of Mohs and Dermatological Surgery Henry Ford Hospital Detroit, MI, USA

This edition first published 2017 © 2017 by John Wiley & Sons Ltd

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The right of Joel L. Cohen and David M. Ozog to be identified as the authors of the editorial material in this work has been asserted in accordance with law.

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Library of Congress Cataloging-in-Publication Data

Names: Cohen, Joel L. (Dermatologist), editor. | Ozog, David M., editor. Title: Botulinum toxins : cosmetic and clinical applications / edited by Joel L. Cohen, David M. Ozog. Description: Chichester, UK ; Hoboken, NJ : John Wiley & Sons Inc., 2017. | Includes    bibliographical references and index. Identifiers: LCCN 2017004474 (print) | LCCN 2017005656 (ebook) | ISBN    9781444338256 (cloth) | ISBN 9781118661864 (Adobe PDF) | ISBN 9781118661857 (ePub) Subjects: | MESH: Botulinum Toxins, Type A–therapeutic use | Cosmetic Techniques Classification: LCC RL120.B66 (print) | LCC RL120.B66 (ebook) | NLM QV 140 | DDC 615.7/78–dc23 LC record available at https://lccn.loc.gov/2017004474

Cover image: (Left) © SEBASTIAN KAULITZKI/Gettyimages; (Right) © iconogenic/Gettyimages Cover design: Wiley

CONTENTS

List of Contributors

About the Companion Website

Video Table of Contents

Foreword: Botulinum Toxins in Dermatology

1 History of Botulinum Toxin for Medical and Aesthetic Use

Sausage Poisoning

Biological Weapon of Warfare

Human Experimentation

The Cosmetic Connection

Properties, Mechanism of Action, and Clinical Effect

A Multitude of Formulations

Cosmetic Applications

Therapeutic Applications

Future Directions

References

2 Anatomy and Aesthetic Principles

Anatomy of Youthful versus Aging Skin

Facial Fat Compartments

Superficial Musculoaponeurotic System

The Facial Nerve

Vasculature of the Face

Muscles of Facial Expression

The Platysma

The Craniofacial Skeleton

Acknowledgements

References

3 Botulinum Toxin: From Molecule to Medicine

Introduction

Botulinum Toxin

Mechanism of Action

Sensory Mechanism of Action

Retrograde Axonal Transport

Immunogenicity

Products and Pharmacology

Summary

References

4 Myobloc

References

5 Abobotulinumtoxin: Development and Aesthetic Usage

Clinical studies

January 12–13, 2009

Treatment of the Upper Face

Treatment of the Lower Face

References

6 IncobotulinumtoxinA (Xeomin

®

/Bocouture

®

)

Introduction

Manufacture and production of incobotulinumtoxinA

Implications of Being Free from Complexing Proteins and Inactive Neurotoxin in IncobotulinumtoxinA

Evidence for Equipotency between IncobotulinumtoxinA and OnabotulinumtoxinA

Aesthetic Applications of IncobotulinumtoxinA

Personal Experience

Summary

References

7 Future Injectable Toxins

Introduction

Xeomin

PurTox

Nabota – DWP-450

Hugel Botulax – Croma Pharma

Neuronox

ChinaTox

Other Toxins

Conclusions

References

8 Reconstitution, Dilution, Diffusion, and Migration of Botulinum Toxin

Introduction

Definitions

Reconstitution

Dilution Volume

Diffusion and Migration

Conclusions

References

9 Patient Selection

References

10 Treatment of the Glabella

Introduction

General Information

Anatomy

Practical Part

Safety Concerns and Adverse Events

References

11 Treatment of the Forehead

Introduction

Anatomy

Aging and the Forehead

Approaching the Patient (Evaluation and Selection)

Toxin and Dosage Selection

Toxin Administration

Key Points of Technique

Contraindications and Complications

Conclusions

References

12 Treatment of the Periocular Area – Crow's Feet, Brow, and Bunny Lines

Introduction

Anatomic Considerations

Patient Selection/Pretreatment Evaluation

Injection Technique

References

13 Contouring of the Lower Face and of the Lower Leg and Calf

Contouring of the Lower Face

Contouring of the Lower Leg

Concluding Remarks: Masseter and Calf Contouring

References

14 Treatment of the Perioral Area

Introduction

Lip Area: Vertical Lip Lines

Chin Area: Chin Dimpling and Mental Crease

Downturned Commissures: Mouth Frown

Gummy Smile

Summary

References

15 Neck Rejuvenation

The Anatomical and Functional Basis of Aging

Signs of Aging in the Neck

Neck Rejuvenation

Conclusion

References

16 Correction of Facial Asymmetry

Introduction

Assessment

Treatment

Synkinesis

Asymmetry of Smile

Asymmetry of Eyelids

Masseter Hypertrophy/ Reshaping of Face

Paresis of the Face

Disorders of Lipodystrophy

Complications of Facial Botulinum Toxin Injections

Case Presentations

Conclusion

References

17 Complications and Diffusion

Introduction

Diffusion

Complications and Adverse Reactions

References

18 Combination Therapy of Botulinum Toxin with other Nonsurgical Procedures

Introduction

Fillers and Botulinum Toxin

Broadband Light Sources/ Nonablative Light-based Treatment and BoNT

BoNT and Laser Resurfacing

BoNT and Other Modalities – Chemical Peels, Chemabrasion, Cosmeceuticals

BoNT and Monopolar Radiofrequency

BoNT and Muscle Stimulation (MS)

Conclusions

References

19 Peri-Procedure Botulinum Toxin for Skin Cancer Patients and Scars

Introduction

Botulinum Toxin for Facial Reconstruction

Botulinum Toxin in Keloidal and Hypertrophic Scars

Conclusion

References

20 Achieving a Natural Look

Introduction

Botulinum Toxin Formulations

Storage and Reconstitution

Patient Assessment, Preparation, Education, and Recommendations

Injection Points, Doses and Techniques

Conclusion

References

21 Special Considerations in Darker Skin

Introduction

Unique Qualities in Skin of Color and Facial Structure

Cosmetic Implications

Conclusion

References

22 Axillary Hyperhidrosis

Introduction

Anatomy and Physiology

Diagnosis and Severity Documentation

Treatment of Axillary Hyperhidrosis

Botulinum Toxin

References

23 Primary Focal Palm, Sole, Craniofacial, and Compensatory Hyperhidrosis

Sweating

Hyperhidrosis

Quality of Life

Measuring Hyperhidrosis

Therapy

Botulinum Toxin Therapy

Axillary Hyperhidrosis

Palmar Hyperhidrosis

Plantar Hyperhidrosis

Facial Hyperhidrosis

Gustatory Sweating (Frey's Syndrome)

Other Sweating Disorders

Use of Botulinum Toxin Type B for Hyperhidrosis

Future Directions

References

24 Topical Botulinum Toxin

Introduction

Current Transepidermal Delivery Mechanisms

Investigational Transepidermal Delivery Systems

Investigational Studies

Future Directions

References

25 Exciting New Uses of Botulinum Toxin Type A: Dermatology/Dermatologic Surgery and Beyond

Introduction

Pain

Pruritus

Role of Hyperhidrosis in Dermatologic Conditions

Summary

References

26 Modulating Affect and Mood with Botulinum Toxin Injections: Psychosocial Implications of Neuromodulators

Introduction

Indicators of Facial Emotion and their Aesthetic Targets for Neuromodulation

Botulinum Toxin in Major Depressive Disorder

Proposed Neuropsychiatric Mechanisms of Botulinum Toxin

Facial Feedback, Emotional Contagion, and Facial Mimicry Hypotheses

Facial Feedback Hypothesis

Facial Mimicry and Emotional Contagion

BoNTA Migration to the Brain

Future Potential Uses of Neuromodulators in Neuropsychiatry Beyond Depression

Conclusion

References

27 OnabotulinumtoxinA (Botox

®

) in Dermatology

Introduction

Efficacy

Storage and Preparation

Treatment

Safety and Complications

Patient Satisfaction

Conclusion

References

Index

EULA

List of Tables

Chapter 2

Table 2.1

Table 2.2

Table 2.3

Chapter 3

Table 3.1

Chapter 4

Table 4.1

Table 4.2

Chapter 5

Table 5.1

Table 5.2

Table 5.3

Table 5.4

Chapter 7

Table 7.1

Chapter 7

Table 7.1

Chapter 10

Table 10.1

Table 10.2

Table 10.3

Chapter 11

Table 11.1

Chapter 13

Table 13.1

Table 13.2

Chapter 16

Table 16.1

Chapter 18

Table 18.1

Table 18.2

Table 18.3

Chapter 20

Table 20.1

Chapter 21

Table 21.1

Chapter 23

Table 23.1

Table 23.2

Table 23.3

Table 23.4

Table 23.5

Table 23.6

Table 23.7

Chapter 25

Table 25.1

Chapter 27

Table 27.1

Table 27.2

List of Illustrations

Chapter 1

Figure 1.1

Dr Alan Scott, the original user of botulinum toxin A initially in monkeys and then in humans, seen in 2010.

Figure 1.2

The Carruthers' first patient treated in the glabella area for cosmetic reasons alone. Seen (a) before frowning; (b) after frowning; (c) before at rest; (d) after at rest.

Figure 1.3

Treatment with 25 units to each masseter muscle: (a) before and (b) after.

Figure 1.4

Scar forehead (a) shortly after injury and (b) 3 months after BTX.

Source:

Carruthers 1992. Reproduced with permission of Lippincott Williams & Wilkins.

Chapter 2

Figure 2.1

Facial fat compartments.

Source:

Rohrich 2007 [14]. Reproduced with permission of Wolters Kluwer Health, Inc.

Figure 2.2

Protagonist/antagonist muscles of facial expression. Redrawn based on an original drawing by Margaret Ditré.

Figure 2.3

Female and male brow position. Redrawn based on an original drawing by David M. Ozog.

Figure 2.4

Transverse rhytids of the forehead (a) relaxed and (b) in animation showing continuous horizontal rhytids across forehead consistent with contiguous frontalis muscle.

Figure 2.5

Insertion of corrugator supercilli onto dermis of skin of medial brow as depicted by the dimple.

Figure 2.6

Vertical frown lines of glabella created by the action of corrugator supercilli.

Figure 2.7

Horizontal frown lines of glabella created by the action of the procerus muscle.

Figure 2.8

Divisions of the orbicularis oculi muscle into orbital and palpebral (preseptal and pretarsal) segments. Redrawn based on an original drawing by Margaret Ditré.

Figure 2.9

(a) Contraction of the orbital portion of the orbicularis oculi resulting in (b) creation of lateral canthal rhytids and depression of tail of brow.

Figure 2.10

Contraction of pretarsal orbicularis oculi creating subtle roll of skin under lower eyelid lashes.

Figure 2.11

Antagonist and protagonist relationship of musculature of upper one-third of face. Redrawn based on an original drawing by Margaret Ditré.

Figure 2.12

Dilation of the nares caused by stimulation of dilator naris and the dilator portion of the levator labii superioris alaeque nasi.

Figure 2.13

Contraction of transverse portion of nasalis muscle creating “bunny lines”.

Figure 2.14

Contraction of depressor septi muscle with resultant derotation (animation ptosis) of nasal tip, decreased tip projection and shortening of the upper lip.

Figure 2.15

Elevators of the upper lip. Redrawn based on an original drawing by Margaret Ditré.

Figure 2.16

Mona Lisa smile secondary to majority of activity of zygomaticus major resulting in elevation of corners of mouth.

Figure 2.17

Canine smile caused by significant activity of levator labii superioris and levator labii superioris alaeque nasi.

Figure 2.18

Full denture smile resulting from contraction of both lip elevators and depressors.

Figure 2.19

Down turning of oral commissures with formation of marionette folds by contraction of depressor anguli oris. Notice also the formation of the prejowl sulcus.

Figure 2.20

Depressors of the lower lip. Redrawn based on an original drawing by Margaret Ditré.

Figure 2.21

Contraction of depressor labii inferioris resulting in depression of lower lip tubercle with mandibular dental show.

Figure 2.22

Contraction of mentalis muscle with cobblestoning appearance to skin of chin and protrusion of lower lip.

Figure 2.23

Sphincteric fibers of the orbicularis oris. Redrawn based on an original drawing by Margaret Ditré.

Figure 2.24

Perioral rhytids caused by contraction of the orbicularis oris.

Figure 2.25

Platysma: Pars modiolaris, labialis, and mandibularis.

Figure 2.26

Contraction of the platysma with depression of the lower lip and corners of mouth.

Chapter 3

Figure 3.1

Molecular structure of the botulinum toxin type A 150 kDa core neurotoxin. The three functional domains are color coded: Yellow: light chain catalytic domain with a zinc atom shown in blue; Red: heavy chain translocation domain; Green: heavy chain binding domain.

Source:

Image courtesy of Lance E. Steward (Allergan plc.).

Figure 3.2

The botulinum neurotoxin type A complex. Shown here is the deduced crystal structure of the botulinum toxin type A complex, consisting of the core neurotoxin of 150 kDa botulinum toxin type A (labeled BoNT/A, purple) in relation to its nontoxic associated neurotoxin proteins. The close association to the non-toxic non-hemeagglutinin protein (NTNH unit, pink) is evident. The other hemagglutinins assemble in a trefoil arrangement as illustrated. Each arm consists of one HA70 (two are visible in this illustration, colored green and blue), one HA 17 (yellow) and two HA33 subunits (orange). The molecular dimensions of the complex are shown in Angstroms – Å.

Source:

Lee 2013 [107]. Used under CC BY 4.0.

Figure 3.3

Multiple steps in the mechanism of action of botulinum toxin type A. This figure illustrates the steps in the mechanism of action of type A botulinum toxin. (1) Following binding to SV2 (pink), the 150 kDa core neurotoxin is internalized into the neuron via a process of endocytosis. (2) The endosome is acidified (3), which facilitates the translocation of the light chain into the neuronal cytosol (4). Once in the neuronal cytosol the light chain of type A botulinum toxin (yellow) cleaves the membrane-associated SNAP-25, one component of the SNARE complex. Another neurotoxin serotype, type B, botulinum toxin cleaves a different protein known as synaptobrevin or vesicle associated membrane protein (VAMP).

Figure 3.4

SNARE Complex. Crystal structure of a core synaptic fusion complex at 2.4 Å resolution.

Source:

Sutton 1998 [109]. Reproduced with permission of Nature Publishing Group.

Chapter 4

Figure 4.1

Pharmacology of botulinum toxins at the neuromuscular junction. SNAP-25 is the target for the type A toxin (red arrow), synaptobrevin is the target for the type B toxin (black arrow).

Figure 4.2

Schemata showing the most common sites of botulinum toxin injections in the upper face. Injections in (a) the glabella; (b) the forehead; (c) the crow's feet. The author prefers to use the conversion of 150 U of type B toxin for 1 U of type A toxin.

Figure 4.3

Technique of (a) glabella and (b) lateral canthal line injections.

Figure 4.4

Treatment of frontalis muscle in (a) a male patient and (b) a female patient with 3,000 U of botulinum toxin type A.

Figure 4.5

Before (a) and after (b) 12 weeks after treatment with 3,000 U of botulinum toxin type B to the glabella.

Figure 4.6

Before (a) and after (b) 12 weeks after treatment with 3,000 U of botulinum toxin type B to lateral canthal lines.

Figure 4.7

Drooping of the left upper eyelid after botulinum toxin type B injection in the glabella. Apraclonidine (0.5%) drops, 3 drops to the affected eye three times a day produces temporary relief of this problem until it completely resolves.

Chapter 5

Figure 5.1

Injection sites for glabellar line treatment. Blue dots, corrugator insertion/orbicularis oculi fibers; yellow dots, corrugator body; green dot, procerus.

Figure 5.2

Forehead line treatment in women. Variation favored by authors to accentuate the lateral arching of the feminine brow pattern.

Figure 5.3

The chemical brow lift: (a) Injection sites for a chemical brow lift if performed alone are shown (5–10 s.U. or 3–5 b.U. per injection site). This patient had a male pattern eyebrow without perceptible arching. She received abobotulinumtoxinA treatment to the lateral tail of each eyebrow (10 s.U. per side), into the corrugators bodies (total 20 s.U.), and to the frontalis (20 s.U.). (b) Posttreatment photo at 33 days reveals an elevated and laterally arched feminine brow.

Figure 5.4

Crow's feet injection. (a) Standard three point crow's feet injection. (b) This patient received 5 b.U. at each point and had an excellent response.

Figure 5.5

Location of lower palpebral injection. A tiny dose of toxin into the lower eyelid can create a more youthful “open” eye (2 s.U. or 0.5–1 b.U.).

Chapter 6

Figure 6.1

Most commercially available BoNTA preparations consist of the neurotoxin and associated complexing proteins (a). The manufacture of incobotulinumtoxinA removes the complexing proteins (b) to leave only the pure active neurotoxin (c) (reproduced with permission of Merz Pharmaceuticals GmbH).

Figure 6.2

Dissociation of the neurotoxin from the complexing proteins occurs in less than a minute at physiological pH (reproduced with permission of Merz Pharmaceuticals GmbH).

Figure 6.3

Percentage of responders at maximum frown at weeks 4 and 12 according to the facial wrinkle scale for the per protocol set. (a) Independent rater assessment based on digital photographs. (b) Investigator assessment based on the live patient.

Source:

Sattler 2010 [6]. Reproduced with permission of Wolters Kluwer Health, Inc.

Figure 6.4

Clinical photographs taken at maximum frown in patients treated with (a) incobotulinumtoxinA and (b) onabotulinumtoxinA.

Source:

Sattler 2010 [6]. Reproduced with permission of Wolters Kluwer Health, Inc.

Figure 6.5

Microinjection technique around the eye. (c) Taken 2 weeks after (a) and (b) at maximum eyebrow elevation. Note smoothing of periorbital wrinkling above eyebrow and at lower lid without losing significant eyebrow height.

Chapter 7

Figure 7.1

Xeomin clinical examples: (a) day 0; (b) 180 days posttreatment. Photos courtesy of Michael H. Gold, MD.

Figure 7.2

Xeomin clinical examples: (a) day 0; (b) 180 days posttreatment. Photos courtesy of Michael H. Gold, MD.

Figure 7.3

PurTox clinical examples, effects seen as: (a) day 0; (b) day 3; (c) day 7.

Figure 7.4

PurTox clinical examples, effects seen as: (a) day 0; (b) day 3; (c) day 7.

Figure 7.5

PurTox clinical examples, effects seen as: (a) day 0; (b) day 180.

Figure 7.6

PurTox clinical examples, effects seen as: (a) day 0; (b) day 180.

Chapter 8

Figure 8.1

Pattern of anhidrosis after BoNTA treatment showing greater area of anhidrosis at the medial injection sites than the lateral injection sites and the greater area of diffusion with BoNTA

2

than BoNTA

1

. The dose ratio was 1 : 2.5 in Patients A and B and 1 : 3 in Patient C. BoNTA, botulinum toxin type A; IM, intramuscular injection; ID, intradermal injection.

Figure 8.2

Same patient at rest and at the maximum voluntary frowning of the forehead area. On day 28, the border area of muscular weakness around the injected points was demarcated with a marker pen, followed by measurement using a standard ruler.

Figure 8.3

Areas of muscular weakness and anhidrosis around the injected points in the frontal area, 28 days later.

Chapter 9

Figure 9.1

During the initial consultation and prior to obtaining an informed consent, the patient is informed of the likely outcome with a thorough discussion of possible complications and adverse effects.

Figure 9.2

Glabellar region with frowning action: (a) before and (b) 1 week after treatment with BoNTA.

Source:

Courtesy of Ryan Greene, MD (PhD, FACS).

Figure 9.3

Activity of the frontalis muscle (a) before and (b) 1 week after treatment with BoNTA.

Source:

Courtesy of Ryan Greene, MD (PhD, FACS).

Chapter 10

Figure 10.1

Procerus and frontalis muscle.

Source:

Bassichis, Benjamin A., and J. Regan Thomas. The use of Botox to treat glabellar rhytids. Facial Plast Surg Clin N Am 13.1 2005;11–14.

Figure 10.2

Corrugator supercilii muscle.

Source:

Bassichis, Benjamin A., and J. Regan Thomas. The use of Botox to treat glabellar rhytids.” Facial Plast Surg Clin N Am 13.1 2005;11–14.

Figure 10.3

The injection points for glabellar line treatment with botulinum neurotoxin type A used in the European studies.

Source:

Rzany, B., B. Ascher, and G.D. Monheit, Treatment of glabellar lines with botulinum toxin type A (Speywood Unit): a clinical overview. J Eur Acad Dermatol Venereol 2010; 24(Suppl 1):1–14.

Figure 10.4

Injection points.

Source:

Salti, G. and I. Ghersetich, Advanced botulinum toxin techniques against wrinkles in the upper face. Clin Dermatol 2008;26(2):182–191.

Chapter 11

Figure 11.1

A 46-year-old woman (a) at rest showing some imprinting of forehead lines, (b) at animation lifting her eyebrows and contracting her frontalis muscle, demonstrating how lines at rest form over time.

Figure 11.2

A 47-year-old at rest, showing imprinted lines in the forehead that demonstrate the anatomic boundaries of the forehead region.

Figure 11.3

A 54-year-old man with a receding hairline.

Figure 11.4

Protagonist/antagonist muscles of facial expression. Redrawn based on an original drawing by Margaret Ditré.

Figure 11.5

Forehead animation pretreatment (a) in a 29-year-old woman treated with 6 U Botox Cosmetic reconstituted 1 U/0.1 cm

3

(b) and posttreatment.

Figure 11.6

Forehead animation pretreatment (a) and posttreatment (b) in a 42-year-old woman treated with 3 U Botox Cosmetic.

Figure 11.7

A 78-year old woman demonstrating profound dermatochalasis. Her eyelids are literally hanging over her eyelashes, and she is using her frontalis muscle even at rest to try to hoist up her eyebrows.

Figure 11.8

A 40-year-old male patient demonstrating significant muscle mass of the frontalis from eyebrow all the way up into the hairline.

Figure 11.9

Animating forehead demonstrating the relationship of the frontalis musculature on shape and positioning of the eyebrows.

Figure 11.10

Receding hairline with high recruitment of muscle fibers, particularly laterally.

Figure 11.11

Arc of BTX effect when glabella treated too broadly, and adjacent spread makes the cut-off of treated versus untreated forehead too distinct.

Source:

Courtesy of David M. Ozog.

Figure 11.12

Missed area on right forehead after forehead BTX treatment by a novice injector.

Source:

Courtesy of David M. Ozog.

Chapter 12

Figure 12.1

Before and after treatment of early static lines of 36 year old female with 8 U onabotulinumtoxin.

Figure 12.2

Before and after treatment of moderate crows feet of 50 year old male with 12 U of incobotulinumtoxin. Note the zygomaticus muscles “pushes” skin into the periorbital region in both the before and after photo and is not improved with toxin injection.

Figure 12.3

Complete treatment of hypertrophic orbicularis oculi muscle will reduce the muscle bulk upon smiling but will also make the eyes appear to be open wider. Patient also had upper blepharoplasty contributing to outstanding aesthetic outcome.

Figure 12.4

Full-fan pattern as described by Kane

et al

. [14] (crinkling of lateral canthal skin from lower lateral brow across the upper eyelid, through the lateral canthus, and across the lower eyelid/upper cheek junction).

Figure 12.5

Central-fan pattern as described by Kane

et al

. [14] (severe wrinkles only in the skin immediately surrounding the lateral canthus).

Figure 12.6

Relaxation of the temporal brow depressor (orbicularis oculi) leading to brow elevation. The patient also had her glabellar complex treated.

Figure 12.7

Superficial blebs demonstrating placement depth of neuromodulator in periocular area will minimize all potential complications.

Chapter 13

Figure 13.1

A cross-sectional view of the masseter muscle along its length.

Figure 13.2

The topographic relationship between the masseter and nose, lips, ear. The majority of the masseter volume is below the line from the columella to the tragus in Frankfort horizontal position. (a) Subnasale; (b) the highest point of the upper vermillion border; (c) the lateral oral commissure.

Figure 13.3

Injection points. A checkerboard pattern is used to create five or six injection points for each masseter.

Figure 13.4

A 34 year old female patient, treated with 25 U of Botox

®

on the left masseter and 30 U on the right masseter. (a) Preinjection; (b) 3 months after injection.

Figure 13.5

Pre- and post-treatment comparison of the static distance between the left and right nasal ala, and the improved width of the lower face at the level of the oral commissure.

Figure 13.6

Serial photography over the course of one year post-injection with maximum efficacy at three months.

Figure 13.7

Significant improvement of masseter hypertrophy in a patient treated every six months with botulinum toxin.

Figure 13.8

The various types of muscular hypertrophy calf. the prominent medial head (a), the prominent medial and lateral heads (b), and the diffusely prominent calf (c).

Figure 13.9

(a) Pre-injection; (b) injection points; (c) attenuation of the medial head of the gastrocnemius.

Figure 13.10

(a) Pre-injection; (b) just prior to the fourth injection; (c) 3 years after the fourth injection.

Figure 13.11

(a) Pre-injection; (b) injection points; (c) 6 months after the second injection.

Chapter 14

Figure 14.1

Pursing the lips will assist in determining the amount and location of the injections. Typical injection points along the vermilion border of 2.5-5 DU or 1-2BU/XU per site are identified by white circles. Additional injection points are located in red but may increase risk of oral incompetence.

Figure 14.2

Having the patient pucker the lips will help to assess where along the vermilion border to place your injection of 2.5-5 DU or 1-2BU/XU per site. A 32 gauge needle with a 1cc no waste syringe is used.

Figure 14.3

Patient animating to help identify the mentalis muscles. Single injection point of 10 DU or 5 BU/XU located in white. Alternatively, 2 separate injection points of 2.5-5 DU or 2.5-5 BU/XU each, identified by red circles.

Figure 14.4

Injection of the DAO at the mandible border (white dot) with 5-10 DU or 2.5-5 BU/XU will allow for upturned corner of the mouth.

Figure 14.5

Gummy smile at baseline (a) and 2 months post treatment with 5 DU to a single injection point per side (white dots) 1 cm lateral to the ala and at the level of the alar rim (b).

Figure 14.6

Summary of recommended injection points marked in white. Red circles indicate additional alternative injection points to consider with caution. Note that the white injection points are at the periphery of the muscles in the perioral area. Red injection points are more central and may carry a higher risk of functional compromise.

Chapter 15

Figure 15.1

(a)

Source

: Reprinted courtesy L. Belhaouari from Ref. [3]; © 2013, L. Belhaouari. (b) Dissection by L. Belhaouari and F. Lauwers., Department of Anatomy Toulouse University, France.

Source

: Reproduced from Ref. [3] courtesy L. Belhaouari; © 2013.

Figure 15.2

Jowl formation. Loss of definition of cervicomental angle and loss of definition of jaw line. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.3

Prominent platysmal bands. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.4

Deep crumpling horizontal lines and superficial photodamage wrinkles. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.5

Position of injection points with 2U onabotuliumtoxin per point for the so called “Nefertiti lift”. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.6

Example of a surgical cervicofacial facelift to restore definition of the cervicofacial oval.

Figure 15.7

Injecting botulinum toxin for platysmal bands perpendicular to the skin and raising a bleb. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.8

Alternative injection technique: beware of submuscular injection.

Figure 15.9

(a) Unilateral platysmal band before treatment at max contraction. (b) Result 1 week after injection of 12 U onabotulinum toxin in unilateral platysmal band. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.10

(a) Before treatment at rest. (b) After treatment with onabotulium toxin at rest. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.11

(a) Before treatment at max contraction. (b) After treatment with onabotulium toxin upon max contraction. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.12

The posterior and lateral fibers of the platysma cover the mandibular edge and are inserted higher up at the labial commissure.

Figure 15.13

Injection point for m. depressor anguli oris with botulinum toxin. Courtesy Dr. K. De Boulle, Belgium.

Figure 15.14

Dissection by L. Belhaouari and F. Lauwers., Department of Anatomy Toulouse University, France.

Source

: Reproduced from Ref. [3] courtesy L. Belhaouari; © 2013.

Figure 15.15

Source

: Reprinted courtesy L. Belhaouari from Ref. [1]; © 2006, L. Belhaouari.

Chapter 16

Figure 16.1

The Synkinesis Assessment Questionnaire.

Figure 16.2

(a) Preoperative photograph; (b) planned intervention overlaying photograph (black x, botulinum toxin injection sites); (c) 2-month postoperative photograph.

Figure 16.3

(a) Preoperative photograph; (b) planned intervention overlaying photograph (black x, botulinum toxin injection site; blue areas. area of placement of filling material); (c) 6-month postoperative photograph after further botulinum toxin injection/filler.

Chapter 17

Figure 17.1

(a) Injection site erythema and (b) hematoma formation immediately following onabotulinumtoxin injection. Photograph courtesy of D. Hexsel, MD.

Figure 17.2

(a) Right eyelid ptosis following onabotulinumtoxin injection of the right frontalis muscle. (b) Partial resolution following 2 U onabotulinumtoxin to the lateral orbicularis oculi.

Figure 17.3

Left eyelid ptosis following onabotulinumtoxin to the glabella. Photograph courtesy of A. Carruthers, MD.

Figure 17.4

Asymmetric lower lip following perioral onabotulinumtoxin injection. Photograph courtesy of A. Carruthers, MD.

Figure 17.5

Asymmetric smile following 2 U of onabotulinumtoxin to the depressor anguli oris, with inadvertent toxin affects to the left depressor labii inferioris.

Chapter 18

Figure 18.1

(a) Before treatment; (b) 3 weeks after one syringe HA to vertical glabellar furrows and 45 units of BoNT to glabella.

Source:

Courtesy of Amy Forman Taub, MD.

Figure 18.2

(a) Melomental folds mouth frown and puckered chin prior to BoNT to depressor anguli oris and chin hyaluronic acid filler to melomental folds and chin. (b) Postcombined treatment with BoNT and filler.

Source:

Courtesy of Amy Forman Taub, MD.

Figure 18.3

Cumulative effects of treatments on one woman's face. (a) Pretreatment; (b) after incobotulinumtoxinA; (c) after incobotulinumtoxinA + CaHA; and (d) after incobotulinumtoxinA + CaHA HA.

Source:

Fink 2014 [22]. Reproduced with permission of Matrix Medical Communications.

Figure 18.4

(a) Before treatment; (b) 6 weeks after one vial Sculptra

®

injections to cheeks, nasolabial folds, and melomental folds, and 4 U BoNT in vertical upper lip lines (as well as glabella and forehead).

Source:

Courtesy of Amy Forman Taub, MD.

Figure 18.5

Left cheek (a) prior to and (b) following BoNT and fractional resurfacing.

Source:

Beer 2007 [43].

Figure 18.6

(a) Before treatment. (b) 2 weeks after full face Erbium:YSGG and 53 U of BoNT to glabella, forehead, and lateral brow depressors.

Source:

Courtesy of Amy Forman Taub, MD.

Figure 18.7

(a) Before treatment. (b) One year after 47 Pan G™ lift treatments and 3 weeks after BoNT to glabella, forehead, and crow's feet.

Source:

Courtesy of Amy Forman Taub, MD.

Figure 18.8

(a) Before treatment. (b) 2 years after 34 Pan G lift treatments and 3 weeks after 54 U BoNT to glabella and crow's feet and six syringes of juvedèrmUltra™ to nasolabial and melomental folds.

Source:

Courtesy of Amy Forman Taub, MD.

Figure 18.9

(a) Before treatment. (b) 5 months after 20 Pan G™ lift treatments and 60 U of BoNT in glabella, forehead, and crow's feet.

Source:

Courtesy of Amy Forman Taub, MD.

Chapter 19

Figure 19.1

A 42-year-old male underwent Mohs surgery for a squamous cell carcinoma. The wound edges could be approximated with the surgeon's hands, but with frontalis contraction there was significant traction laterally widening the wound. The wound was repaired and his frontalis was treated immediately post-operatively with 3000 U of rimabotulinumtoxinB. Effect of the toxin is shown at 48 hours after the injection. Complete effect of the type B toxin is still present at 2 weeks following the repair.

Figure 19.2

A 33-year-old male underwent Mohs surgery for a basal cell carcinoma on the root of the nose. His postoperative defect is shown and a rhombic transposition flap used for the repair. 24 U of onobotulinumtoxinA was placed intraoperatively into the entire glabellar complex (procerus, depressor supracilli, and corrugator supercilli muscles). The result at 4-month follow-up is shown.

Chapter 20

Figure 20.1

Technique of injection in the glabellar region.

Figure 20.2

Periorbital area before BoNTA treatment.

Figure 20.3

Same patient as shown in Figure 20.2 after BoNTA injections; no improvements in the skin redundancies in the lower eyelid were observed.

Figure 20.4

Injection points for the periocular area.

Figure 20.5

Safe injection sites should be above a line between the zygomatic arch and malar eminency. This is of particular importance for patients who underwent one or more face lifts.

Figure 20.6

Periorbital area before BoNTA treatment combined with fillers.

Figure 20.7

Same patient as shown in Figure 20.6 after combined treatment.

Figure 20.8

Injection points for the treatment of horizontal forehead lines.

Figure 20.9

Patient before forehead treatment with BoNTA.

Figure 20.10

Same patient as shown in Figure 20.9 with brow lift effect after forehead treatment with BoNTA.

Figure 20.11

Presence of bunny lines before treatment with BoNTA in the upper third of the face.

Figure 20.12

The mentalis muscle is an agonist and supports the contraction of the DAO muscle.

Chapter 21

Figure 21.1

(a) Baseline. (b) Mild elevation of brow after treatment with BTA, preserving lateral apex.

Figure 21.2

(a) Baseline: downward slanted canthus accentuated in dynamic position with rhytids along the orbital rim. (b) After: improvement of canthal angle in dynamic position with softening of rhytids and lateral position of brow apex.

Chapter 22

Figure 22.1

Minor starch test showing true sweaty (deep purple) area and regions of false positive test.

Figure 22.2

Right axilla of a 28-year-old woman before treatment.

Figure 22.3

Left axilla of the same patient as shown in Figure 22.2 before treatment.

Figure 22.4

Right axilla 21 days after injection of 50 U of onabotulinumtoxinA.

Figure 22.5

Left axilla 21 days after injection of 50 U of onabotulinumtoxinA.

Figure 22.6

Right axilla 15 months after injection of 50 U of onabotulinumtoxinA.

Figure 22.7

Left axilla 15 months after injection of 50 U of onabotulinumtoxinA.

Chapter 23

Figure 23.1

Sites of hyperhidrosis reported to be problematic.

Figure 23.2

Iodine is applied to a clean dry surface.

Figure 23.3

Cornstarch is applied sparingly after iodine has dried.

Figure 23.4

Variation in hand size needs to be taken into consideration when dosing botulinum toxin for treatment of palmar hyperhidrosis.

Figure 23.5

The palm is innervated by the ulnar, median, and radial nerves. Nerve blocks may be performed at the level of the wrist.

Figure 23.6

Use of a two-vibrator technique for pain control.

Figure 23.7

Ice and pressure should be applied for 7–10 seconds.

Figure 23.8

Typical injection pattern for palmar hyperhidrosis.

Figure 23.9

When using a combination of ice and vibration, ice is applied for 7–10 seconds and vibration is applied in the treatment area immediately before injection.

Figure 23.10

Facial starch-iodine test demonstrating excessive sweating of the forehead and to lesser extent the upper lip.

Chapter 24

Figure 24.1

Small molecules can penetrate skin directly (left), while larger molecules have traditionally required direct injection to penetrate the skin (right). Reproduced with permission of Revance Therapeutics.

Figure 24.2

The epidermis consists of cells interspersed in a lipid matrix (left) which demonstrates a lamellar structure on further examination (right). Reproduced with permission of Revance Therapeutics.

Figure 24.3

The lipid matrix provides a route between skin cells which permits passive, non-energy dependent, “lipid rafting” of molecules through the skin, a very slow and concentration dependent process. Reproduced with permission of Revance Therapeutics.

Figure 24.4

Iontophoresis uses an electric current to drive molecules below the active electrode into the skin, a process that is dependent on current and concentration. The method has been used for hyperhidrosis but is cumbersome at best. Reproduced with permission of Revance Therapeutics.

Figure 24.5

The TAT gene has a protein transduction domain (PTD) which binds noncovalently to the relatively negatively charged botulinum toxin. The toxin becomes surrounded by the peptides with the PTDs binding to cell surfaces and permitting active energy transport of the toxin into the cell, then out the cell and into the next cell. Reproduced with permission of Revance Therapeutics.

Figure 24.6

Now instead of depending on passive movement through the intracellular spaces, the peptide-covered toxin is actively transported through cells into the neighboring cell, repeating the process until the toxin exits the epidermis on the dermal side. Reproduced with permission of Revance Therapeutics.

Figure 24.7

The combination of toxin plus peptide shows classic inhibition of muscular action of the mouse's hind foot, with inhibition significantly greater than that of topical botulinum toxin without the peptide. Reproduced with permission of Revance Therapeutics.

Figure 24.8

Toxin plus peptide topically demonstrated a qualitative inhibition of sweating as demonstrated by the Minor starch iodide test of axillary sweating compared to baseline.

Source:

Glogau 2007 [20]. Reproduced with permission of John Wiley & Sons.

Figure 24.9

Single application of toxin plus peptide demonstrated qualitative inhibition of muscular movement in the lateral canthal lines evaluated at smile and rest.

Figure 24.10

The toxin-peptide complex demonstrated an increasing effect with increasing doses, in some cases comparable to that seen with injected toxin.

Figure 24.11

Measurement of canthal lines at rest was a more stable measurement endpoint with higher reliability.

Figure 24.12

Representative subject photographs showing shorter and shallower LCLs. (a) Screening, (b) 4 weeks post first application of RT001, and (c) 8 weeks post first application of RT001 (4 weeks post second application of RT001).

Source:

Brandt 2010 [24]. Reproduced with permission of John Wiley & Sons.

Chapter 25

Figure 25.1

Neuropeptides likely blocked by botulinum toxin type A. CGRP: Calcitonin Gene Related Peptide; Ach: Acetylcholine; VIP: Vasoactive Intestinal Peptide.

Figure 25.2

Herpes zoster, photo courtesy of Drs. Jason Emer and Gary Goldenberg.

Figure 25.3

Piloleimyoma, photo courtesy of Dr. Michael Paltiel.

Figure 25.4

Lichen simplex chronicus (LSC), photo courtesy of Dr. Tor Shwayder.

Figure 25.5

Dyshidrotic eczema.

Figure 25.6

Inverse psoriasis, photo courtesy of Dr. Tor Shwayder.

Figure 25.7

Hailey-Hailey, photo courtesy of Dr. Henry Lim.

Figure 25.8

Darier's disease, photo courtesy of Dr. Tor Shwayder.

Figure 25.9

Epidermolysis bullosa simplex, photo courtesy of Dr. Tor Shwayder.

Figure 25.10

Vitiligo, photo courtesy of Dr. Tor Shwayder.

Figure 25.11

Ulceration.

Chapter 26

Figure 26.1

The six clear facial indications of emotion — happy, sad, fear, anger, surprise, and disgust.

Figure 26.2

Muscles of facial expression and the expressions they participate in.

Source:

Victoria Contreras. Reproduced with permission of ARTNATOMYA.

Figure 26.3

The muscles of facial expression that play roles in the facial expression of a single emotion: anger.

Source:

Alam 2008 [25]. Reproduced with permission of Elsevier.

Figure 26.4

Subjects asked to hold a pen between their teeth to simulate a grin found a cartoon to be funnier than did subjects who were not asked to perform this maneuver.

Source:

Alam 2008 [25]. Reproduced with permission of Elsevier.

Figure 26.5

Subjects who had two golf tees attached to either side of their foreheads and were asked to try to move these together to simulate a frown concurrently rated unpleasant photographs more negatively than subjects who viewed the same photographs but did not simultaneously attempt the movement.

Source:

Alam 2008 [25]. Reproduced with permission of Elsevier.

Chapter 27

Figure 27.1

Vial types by units. Each vial of BoNTA-ONA contains either 50 U or 100 U. Potency is determined by the amount of saline used for reconstitution.

Figure 27.2

Reconstitution solutions. Left, 0.9% sterile preservative-free saline; right, preserved isotonic saline.

Figure 27.3

Syringes and needles. Some physicians prefer to use a 32-guage needle (a) TSK SteriJect, TSK Laboratory, Tochigi-Ken, Japan, rather than the more common 30-gauge needle (b) BD Precision Glide, Becton Dickinson & Co, Franklin Lakes, NJ, to help reduce side effects such as pain during injection. Also, an array of syringe types is available for injection and can be chosen based on personal preference. (c) Injekt-F Tuberkulin Low Waste Syringe, B. Braun Medical, Bethlehem, PA;. (d) BD Leur-Lok Tip Syring, Becton Dickinson & Co, Franklin Lakes, NJ; (e) BD Tuberculin Slip Tip Syringe, Becton Dickinson & Co, Franklin Lakes, NJ; (f) BD SafetyGlide Insulin Syringe, Becton Dickinson & Co, Franklin Lakes, NJ.

Figure 27.4

Female forehead anatomy. Typical rhytides of the frontalis muscle are evident during forehead elevation with an arched appearance of the eyebrows. Notice the frontalis is one large muscle with broad insertions, rather than two discreet muscles with specific insertions.

Figure 27.5

Male forehead anatomy. Male forehead rhytides are typically large and broad as compared to females, given an increased distance between the eyebrows and the frontal hair line. Notice the skin is more glabrous, due to increase sebaceous activity. Also, here is a good example of the frontalis muscle as two discrete muscle bellies with insertions more prominent over the eyebrows and with sparing of part of mid-upper forehead. Further, the male eyebrows are more horizontal and less arched as compared to females.

Figure 27.6

Palmar hyperhidrosis. Clammy hands with palmar glistening in a patient with severe hyperhidrosis.

Figure 27.7

Iodine starch test. Iodine starch test is used as an aid for identifying localized areas of sweating in order to concentrate toxin injection for increased clinical efficacy and patient satisfaction.

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List of Contributors

Alan Ackerman, PhD

Master Medical Scientific Liaison, Retired Ackerman LLC Greeley, USA

Ki Young Ahn, MD (PhD)

Director Dr. Ahn's Aesthetic & Plastic Surgical Clinic Daegu, South Korea

Murad Alam, MD (MSCI, MBA)

Professor and Vice-Chair Department of Dermatology Section of Cutaneous and Aesthetic Surgery Departments of Dermatology Otolaryngology, and Surgery Northwestern University Chicago, USA

Shawn Allen, MD (FAAD, FACMS)

Director and Founder Dermatology Specialists Boulder, USA Assistant Clinical Professor University of Colorado Department of Dermatology Boulder, USA

Ada Regina Trindade de Almeida, MD

Medical Assistant Dermatology Clinic Hospital do Servidor Público Municipal de São Paulo São Paulo, Brazil

Cheré Lucas Anthony, MD

Medical Director Rendon Center for Dermatology and Aesthetic Medicine Boca Raton, USA Voluntary Faculty Dermatology and Cutaneous Surgery University of Miami, Miller School of Medicine Miami, USA

John P. Arkins, BS

DeNova Research Chicago, USA

Eileen Axibal, MD

Department of Dermatology University of Colorado Aurora, USA

Lakhdar Belhaouari, MD

Director Centre de Chirurgie Esthétique et Medecine Esthétique Jules Guesde Toulouse, France

Anthony V. Benedetto, DO (FACP, FCPP)

Clinical Professor of Dermatology Perelman School of Medicine University of Pennsylvania PA, USA Medical Director Dermatologic SurgiCenter Philadelphia and Drexel Hill PA, USA

Brian S. Biesman, MD (FACS)

Assistant Clinical Professor Ophthalmology Dermatology, Otolaryngology Vanderbilt University Medical Center Nashville, TN, USA

Donna Bilu Martin, MD (FAAD)

Dermatologist, Premier Dermatology Aventura, USA Volunteer Professor of Dermatology and Cutaneous Surgery Miller School of Medicine University of Miami Miami, USA

Andrew Blitzer, MD (DDS, FACS)

Director NY Center for Voice and Swallowing Disorders Senior Attending Physician St. Luke's/Roosevelt Hospital Professor of Clinical Otolaryngology Columbia University College of Physicians and Surgeons New York, USA

Alastair Carruthers, FRCPC

Clinical Professor Department of Dermatology and Skin Science University of British Columbia Vancouver, Canada

Jean Carruthers, MD (FRCS(C), FRCOphth)

Clinical Professor Department of Ophthalmology and Visual Sciences University of British Columbia Vancouver, Canada

Lesley F. Childs, MD

Attending Physician Assistant Professor of Laryngology, Neurolaryngology, and Professional Voice UT Southwestern, Dallas, TX

Chinobu Chisaki, MD

Medical Assistant Dermatology Clinic Hospital do Servidor Público Municipal de São Paulo São Paulo, Brazil

Joel L. Cohen, MD (FAAD, FACMS)

Director AboutSkin Dermatology and DermSurgery Greenwood Village and Lone Tree Colorado, USA Associate Clinical Professor University of Colorado Department of Dermatology Denver, USA Assistant Clinical Professor University of California Irvine Department of Dermatology Irvine, USA

Carolee M. Cutler Peck, MD

Ophthalmic and Plastic and Reconstructive Surgeon SouthEast Eye Specialists Knoxville, USA

Steven H. Dayan, MD (FACS)

Clinical Assistant Professor of Otolaryngology Chicago Centre for Facial Plastic Surgery University of Illinois Chicago Chicago, USA

Koenraad De Boulle, MD

Aalst Dermatology Clinic Aalst, Belgium

Chérie M. Ditre, MD

Associate Professor Department of Dermatology University of Pennsylvania School of Medicine Philadelphia, USA

Jason J. Emer, MD

Cosmetic Dermatology and Body Contouring Private Practice Beverly Hills, CA

Ramin Fathi, MD

Resident Physician Department of Dermatology University of Colorado Aurora, USA

Lauren Fine, MD (FAAD)

Associate Dermatologist & Cosmetic Fellow Advanced Dermatology, LLC Chicago, USA

Timothy Corcoran Flynn, MD

Clinical Professor of Dermatology University of North Carolina at Chapel Hill Chapel Hill, USA Medical Director Cary Skin Center Cary, USA

Conor J. Gallagher, PhD

Executive Director Medical Affairs Facial Aesthetics Allergan plc Irvine, USA

Hayes B. Gladstone, MD

Gladstone Clinic San Ramon, USA

Dee Anna Glaser, MD

Professor and Interim Chairman Department of Dermatology Saint Louis University School of Medicine Saint Louis, USA

Richard G. Glogau, MD

Clinical Professor of Dermatology University of California San Francisco USA

Michael H. Gold, MD

Medical Director Gold Skin Care Center Nashville, USA

David J. Goldberg, MD (JD)

Clinical Professor of Dermatology Department of Dermatology Icahn School of Medicine at Mount Sinai New York, USA Skin Laser and Surgery Specialists of New York and New Jersey New York, USA

Timothy M. Greco, MD (FACS)

Clinical Assistant Professor Department of Otolaryngology-Head and Neck Surgery Division of Facial Plastic Surgery University of Pennsylvania School of Medicine Philadelphia, USA

Ryan M. Greene, MD (PhD, FACS)

Director Plastic Surgery & Laser Center Fort Lauderdale, USA

James L. Griffith, MD (MSci)

Dermatology Resident Department of Dermatology Henry Ford Hospital Detroit, USA

Camile L. Hexsel, MD (FAAD, FACMS)

Dermatologist and Dermatologic Surgeon Madison Medical Affiliates Mohs Surgery Glendale and Waukesha USA

Dóris Hexsel, MD

Dermatologist and Dermatologic Surgeon Brazilian Center for Studies in Dermatology Porto Alegre, Brazil

Matthias Imhof, MD (DALM)

Board Certified Dermatologist and Allergologist Aesthetische Dermatologie im Medico Palais Bad Soden, Germany

Julia D. Kreger, MD

University of Colorado Dermatology Colorado, USA

Ulrich Kühne, MD (DALM)

Board Certified Dermatologist and Allergologist Aesthetische Dermatologie im Medico Palais Bad Soden, Germany

Matteo C. LoPiccolo, MD

Henry Ford Health System Department of Dermatology Detroit, USA

Stephen Mandy, MD (FAAD)

Volunteer Professor of Dermatology and Cutaneous Surgery Miller School of Medicine University of Miami Miami, USA Premier Dermatology South Beach Dermatology Miami Beach, USA

Suveena Manhas-Bhutani, MD

Sadick Dermatology and Research New York, USA

Ellen S. Marmur, MD (FAAD)

Director, Marmur Medical Mount Sinai School of Medicine Department of Dermatology New York, USA

Adam R. Mattox, DO (MS)

Micrographic Surgery & Dermatologic Oncology Fellow Department of Dermatology Saint Louis University School of Medicine Saint Louis, USA

Gary D. Monheit, MD

Total Skin and Beauty Dermatology Center PC Private Practice Associate Clinical Professor Department of Dermatology Department of Ophthalmology University of Alabama at Birmingham Birmingham, USA

Girish S. Munavalli, MD (MHS, FACMS)

Medical Director, Dermatology, Laser, and Vein Specialists of the Carolinas, PLLC Charlotte, USA

David M. Ozog, MD (FAAD, FACMS)

Chair, Department of Dermatology C.S. Livingood Chair in Dermatology Director of Cosmetic Dermatology Division of Mohs and Dermatological Surgery Henry Ford Hospital Detroit, MI, USA

Mee young Park, MD (PhD)

Department of Neurology Yeungnam University College of Medicine Daegu, South Korea

Dennis A. Porto, MD

Department of Dermatology Henry Ford Hospital Detroit, USA

Molly C. Powers, MD

Dermatology Senior Resident Department of Dermatology Henry Ford Hospital Detroit, USA

Marta I. Rendon, MD (FAAD, FACP)

Medical Director, Rendon Center for Dermatology and Aesthetic Medicine Boca Raton, USA Voluntary Associate Clinical Professor University of Miami Dermatology Department Miami, USA

Scott Rickert, MD (FACS)

Attending Physician Assistant Professor of Otolaryngology, Pediatrics, and Plastic Surgery NYU Langone Medical Center New York, USA

Farhaad R. Riyaz, MD

Henry Ford Health System Department of Dermatology Detroit, USA

Neil S. Sadick, MD (FACP, FAAD, FAACS, FACPh)

Clinical Professor Weill Cornell Medical College Cornell University New York, USA

Roberta Sengelmann, MD

President and Owner Santa Barbara Skin Institute Associate Clinical Professor UCI Dermatology Santa Barbara, USA

Carolina Siega, BSc

Biologist Brazilian Center for Studies in Dermatology Porto Alegre, Brazil

Rachel Simmons, MD (FAAD)

Dermatologist Dermatology Specialists Boulder, USA

Kevin C. Smith, MD (FRCPC (DERM))

Private Practice Dermatologist Niagara Falls Ontario, Canada

Amy Forman Taub, MD

Director Founder Advanced Dermatology, LLC Assistant Professor Northwestern University Medical School Chicago, USA Assistant Clinical Professor Northwestern University Lincolnshire, USA

Neal D. Varughese, MD (MBA)

Skin Laser and Surgery Specialists of New York and New Jersey New York, USA

Heidi Waldorf, MD

Mount Sinai School of Medicine Department of Dermatology New York, USA

About the Companion Website

Don't forget to visit the companion website for this book:

www.wiley.com/go/cohen/botulinum

This site hosts valuable video materials to enhance your learning:

Dr Cohen and Dr Ozog present several patient cases, focusing on patient evaluation, preparation for toxins, and specific injection techniques. Each patient is appraised carefully and optimal injection techniques are discussed, along with methods for avoiding adverse effects, and ways to minimize injection points and related bruising. One week follow up videos will highlight optimization of results.

Video Table of Contents

Introduction from Dr Joel L. Cohen and Dr David M. Ozog

Discussion on reconstitution techniques from Dr Joel L. Cohen and Dr David M. Ozog

Patient Cases

Patient 1, 66-year old female,

Dr Joel L. Cohen, Dr David M. Ozog

Evaluation

Glabellar Complex

Lateral Canthal Area

One Week Follow Up

Patient 2, 43-year old female,

Dr Joel L. Cohen, Dr David M. Ozog

Evaluation

Forehead

Glabellar Complex

Lateral Canthal Area

One Week Follow Up

Patient 3, 69-year old female,

Dr Joel L. Cohen, Dr David M. Ozog

Evaluation

Glabellar Complex

Lateral Canthal and Infraorbital Area

One Week Follow Up

Patient 4, 48-year old female,

Dr Joel L. Cohen, Dr David M. Ozog

Evaluation

Glabellar Complex

Lateral Canthal Area

One Week Follow Up

Patient 5, 72-year old female,

Dr Joel L. Cohen, Dr David M. Ozog

Evaluation

Glabellar Complex

Lateral Canthal Area

One Week Follow Up

Patient 6, Treatment of Platysmal Bands in female,

Dr Koen De Boulle (narrated by Dr Dennis A. Porto)

Patient 7,

Dr David M. Ozog

Depressor Septi Nasi

Mentalis and Depressor Anguli Oris

Platysmal Bands

One Week Follow Up for Platysmal Bands

Patient 8, Treatment of Lower Face and Neck in 63-year old female patient,

Dr Gary D. Monheit (narrated by Dr Dennis A. Porto)

Foreword: Botulinum Toxins in Dermatology

Alastair Carruthers, FRCPC1, Jean Carruthers, MD, FRCSC2

1Clinical Professor, Department of Dermatology and Skin Science, University of British Columbia

2Clinical Professor, Department of Ophthalmology and Visual Sciences, University of British Columbia

Clostridium botulinum (C. botulinum), discovered over a century ago as the bacterium responsible for botulism, his risen through medical ranks to become the basis of what is one of the most requested procedures in facial rejuvenation and accepted therapeutic options for use in a variety of clinical scenarios.

Until the 1980s, botulinum toxin (BoNT) was merely a potent toxin with devastating effects and up to a 65% mortality rate. The history of food‐borne illness to therapeutic agent is checkered with tainted blood sausages, brilliant clinical scientists, biological warfare and, at the heart of it all, an understanding that this toxin that led to so many deaths and devastated the canning industry in the 1930s, could somehow be of clinical use.

Interestingly, the clinical use of BoNT has proven circular: its initial forays into therapeutics, as a nonsurgical treatment for strabismus and blepharospasm, sparked discoveries in facial rejuvenation; the enormous acceptance of its cosmetic use has in turn fuelled the expansion and tremendous growth in therapeutic fields, leading to an even greater clinical experience and understanding of mechanism of action and potential indications for use.

In the last 5 years, the use of BoNT has grown exponentially and now accounts for about half (along with soft‐tissue augmenting agents) of all nonsurgical cosmetic procedures in North America. The reasons for such an enthusiastic response to the toxin may be found in the target populations. As we age, the skin atrophies and sags, bones shift, and lines and wrinkles become more prominent. Ameliorating those wrinkles is one of the primary methods of turning back the clock. The fact that BoNT is able to accomplish this feat with minimal downtime or side effects has contributed greatly to its rise in popularity. Moreover, BoNT may be considered a preventative anti‐aging modality, appealing to a younger population in addition to those seeking to eradicate already established rhytides and folds.

Therapeutically, indications for BoNT have progressed beyond movement disorders and spasticity to investigations into potential uses for a multitude of disorders and syndromes, including those involving pain, the endocrine system (sweat, lacrimal, and salivary glands), and the central nervous system, among others. Clinicians from nearly all therapeutic specialists have turned their attention, at least in part, to possible applications of BoNT.

It is becoming more difficult to stay abreast of new developments. This book has been compiled to highlight not only the