An alternative approach to perioral rhytides

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Botulinum Toxin and Chemical Peels

Photodamage is the primary trigger for extrinsic aging. It results from cumulative exposure to g ultraviolet light and is responsible for many unwanted aging signs. The most common clinical signs include aging spots on a shallow colored skin, keratoses, static rhytids, telangiectasia and loss of elasticity. The degree of photodamage varies from patient to patient and can be mild, moderate or severe. Fillers and botulinum toxin alone will not be able to solve every skin wrinkle. The best way to reduce static wrinkling is through ablative methods such as chemical peels. Skin renewal and collagen remodeling improves the appearance of photo-damaged skin. With dermal thickening, less wrinkling appears due to muscle traction onto the skin. The fact that superficial skin wrinkling may be treated with chemical peels does not mean that dynamic wrinkles should not be treated. Both methods should be used together to allow better results. Why combine BNT-A and chemical peels Because the BNT-A...

Botulinum Toxin and Facelift

With the development of less and less invasive procedures, the upper third is now basically treated with BNT-A alone, which promotes rejuvenation improvement such as brow lifting, erasing of horizontal lines in the forehead and vertical lines in the glabella area without scarring or downtime. So mini-lifts may focus basically on the middle and lower face and neck. Although mini-lifts are less invasive that the conventional facelift, a shorter but still not that short downtime is nevertheless an issue (Fig. 8.6a,b).

And Laser Resurfacing

Laser resurfacing is another effective ablative method for the treatment of static rhytids. The Fig. 8.ia,b. Crow's feet area before and after combination treatment of BNT-A injection with a light chemical peel. Please note the nice wrinkling reduction and the lightening of the skin Fig. 8.ia,b. Crow's feet area before and after combination treatment of BNT-A injection with a light chemical peel. Please note the nice wrinkling reduction and the lightening of the skin Fig. 8.2a,b. One month after full face laser resurfacing the patient was again depicting lines while frowning. As this would jeopardize the resurfacing result the patient was treated with BNT-A in the glabella area. After BNT-A treatment there is no visual line formation during frowning. This case demonstrated the usefulness of the combination of BNT-A with ablative procedures Fig. 8.2a,b. One month after full face laser resurfacing the patient was again depicting lines while frowning. As this would jeopardize the...

Patient Selection

Glabellar wrinkles, because they are present in a static situation. Here, usually an additional treatment with injectable fillers is necessary to obtain good results. Again, kinetic and hyperkinetic patients are best to treat. Kinetic patients only produce gla-bellar wrinkles if they want to denote anger or concentration and the lines are mainly superficial. Hyperkinetic patients present glabellar lines independently of willing to express anger or concentration. Lines are seen in dynamic situations and are deeper. Hypertonic patients are more difficult to treat (Figs. 5.60-5.62). In these patients BNT-A has only a moderate effect on

Viscoaugmentation A Hyaluronan Gels

Tissue engineering with viscoelastic hyaluronan focused first on its use as a tissue filler or tissue augmentator (viscoaugmentation). Unlike collagen and non-biological tissue fillers, hyaluronan is an extremely elastic molecule and as such provides elasticity to the intercellular spaces into which it is injected. Hylan B gel was first used for viscoaugmentation of the vitreus after retinal detachment surgery, and later for correcting facial wrinkles and depressed scars for vocal cord augmentation in glottal insufficiency and augmentation of the connective tissue in sphincter muscles to treat urinary incontinence.

Efficacy Optimal Dosage

Injektion Points Glabella

What should efficacy measure BNT targets the activity of the mimic muscles. Therefore, the ability of the toxin to reduce muscular movements should be measured. Usually it is not the muscular strength itself, but the effect of the reduction of muscular strength on the severity of wrinkles, which is measured by clinical scales. In most clinical trials four-point rating scales (with o for no and 3 for severe wrinkles) have been used to measure efficacy (Honeck et al. 2003). rhytids in females. Eighty female subjects with moderate to severe wrinkles at maximum frown entered the study. Patients were randomly administered 10, 20, 30 or 40 Botox U in seven injection points (Fig. 1.2). Objectively, 10 U of BNT type A was significantly less effective than 20, 30 or 40 U. The relapse rate at 4 months was significantly higher in the 10-U group (83 ) versus 40, 30 or 20 U (28 , 30 and 33 respectively). The authors concluded that 20-40 Botox U was significantly more effective at reducing...

Scientific Foundations

Moisturizers, designed to reduce skin dryness, typically use skin-friendly substances, such as milk. The skin cells absorb the active ingredient of the product to produce the softening effects. Certain chemical peels used as anti-wrinkle agents effectively remove the upper dead cell layers of the skin, thereby leaving it smooth and erasing fine lines. Most cosmetics work in similar ways, either by being absorbed by skin cells or by removing dead skin cells.

Antagonists and Synergists

As mentioned above, the best candidates for BNT-A lifting are those who do not present significant saggy skin in the mid and lower face and neck. They are from 30 to 50 years of age and present no important asymmetries during animation. They are precisely those patients who are too young for a surgical facelift, even a minor one, but would benefit from a mild non-surgical face lift. The ideal patient for BNT-A lifting usually presents the typical signs (Table 6.9)

The Microlift Procedure BNTA as an Important Ally

The technique utilizes a variety of biodegradable injectable products and BNT-A to improve appearance with a fast and relatively painless lunchtime procedure. This lift has been expanded to the microlift procedure. The microlift facelift appeals to the patient seeking a more long-lasting improvement than fillers and surface treatments offer but without the discomfort and cost of a surgical facelift. The technique utilizes three common treatments to improve facial contours liposuction of the neck and under the chin, injection of facial fillers into wrinkles and folds, and suspension of facial muscles using polypropylene or mersilene threads. Alongside this, injection of botulinum toxin in the upper, mid and lower thirds is also a rule. Chemical peels can be added for some patients to further improve skin appearance. Patients appreciate that the microlift technique offers little scarring, minimal discomfort, and a quick recovery time. (Fig. 8.7a,b) Fig. 8.6a,b....

Patient Selection and Evaluation

Female with hyperkinetic upper lip wrinkles Fig. 5.88. Female with hyperkinetic upper lip wrinkles 2 before treatment of the philtrum area weeks after treatment of the philtrum area with BNT-A Fig. 5.87. Female with hyperkinetic upper lip wrinkles Fig. 5.88. Female with hyperkinetic upper lip wrinkles 2 before treatment of the philtrum area weeks after treatment of the philtrum area with BNT-A Fig. 5.89. Female with hyperkinetic lip wrinkles before Fig. 5.90. Female with hyperkinetic lip wrinkles 2 weeks treatment after treatment with BNT-A in the upper and the lower lip Fig. 5.89. Female with hyperkinetic lip wrinkles before Fig. 5.90. Female with hyperkinetic lip wrinkles 2 weeks treatment after treatment with BNT-A in the upper and the lower lip Upper lip wrinkles

Hyperkinetic Patients

Hyperkinetic patients have stronger muscles and the result after the first injection can be almost complete removal of wrinkles. However, they normally need repeated doses or higher doses to obtain perfect results. After treatment the patient still presents some muscle contraction at the glabella area that may be reinjected with BNT-A to obtain optimal results Fig. 2.ioa,b. Hyperkinetic patients have stronger muscles and the result after the first injection can be almost complete removal of wrinkles. However, they normally need repeated doses or higher doses to obtain perfect results. After treatment the patient still presents some muscle contraction at the glabella area that may be reinjected with BNT-A to obtain optimal results

Dysport

The frequency of re-injection visits depends on several factors the regaining of muscular movement (which depends on the strength of muscles and the initial dose), the consequently increased visibility of mimic wrinkles, and other factors such as costs.

Outcome Analysis

It depends Injectors should initially analyze the muscular pattern, adaptation behavior and what would promote a cosmetic upgrade for the patient. If we didactically divide the face into three thirds, we have to try to make them harmonious among themselves. Botulinum toxin is a powerful agent for the upper third it can erase wrinkles, lift the eyebrows and improve the eye contour. If the patient presents severe photo-damage, the skin of the three thirds is compromised and what can be improved in the skin appearance in the upper third, can barely be achieved in the lower and even less in the mid third. The question that should be asked now is Is it reasonable to give a full treatment in the upper third while the mid and lower thirds cannot achieve the same performance Botulinum toxin treatments were carried out like this previously, and this may be one of the main reasons that it frightened many patients.

Cosmetic Filler

In skin, there is a need for a tissue 'filler' for cosmetic reasons. Currently, a popular treatment for wrinkles is the use of botulinum toxin. The effect of this agent is to cause the paralysis of muscles, which influences the development of wrinkles. Comparative studies of using botulinum toxin alone or in conjunction with HA in form of Hyalan B indicate that moderate to severe rhytides were treated better by botulinum toxin combined with HA than with botulinum toxin alone (115). This study was repeated with an HA-botulinum toxin combination where the HA was produced by a non-animal source. Restylane is an HA produced by bacterial fermentation incorporating recombinant gene technology.

Mephisto Sign

When restricting the forehead treatment to the area between the midpupillary lines in some patients, especially hypertonic patients, lateral movement of the m. frontalis will produce more visible wrinkles or make the existing wrinkles more visible the so-called Mephisto sign. The Mephisto sign may be carefully corrected with an injection in the point of maximum contraction when the patient raises the forehead. The injection point should be approximately 1 cm above the orbital rim. However, be aware that this additional injection point may lead to brow ptosis.

Crows Feet

In general, patients with fair skin and blond or red hair show the effects of aging at an earlier stage. Blue or green eyes are more sensitive to daylight and as a consequence, squinting in bright sunlight may mechanically contribute to the lateral periorbital skin wrinkles. Patients with darker complexions have more protection, especially if their skin is more sebaceous. Eyelid skin wrinkling may also result from ultraviolet Patients with thinner skin present very delicate wrinkling and patients with thicker skin present more prominent and deeper wrinkles. The more atrophic the skin is, the greater the quantity of fine wrinkles that may be found. Wrinkle extension also varies according to the 5 muscle size, and some wrinkles can go down to the cheek area.

Gene Therapy

Introducing a gene into a cell is a complex and often dangerous business that depends on the natural ability of viruses to infect cells. Some RNA viruses, called retroviruses, have the added ability to incorporate their genome into cellular chromosomes. Scientists have developed methods for adding a human gene to the retroviral genome, so that when the retrovirus infects a cell and inserts its genome into a chromosome, it has, in effect, delivered and installed the therapeutic gene. To be sure, there are many wrinkles in this procedure, and much work is needed to ensure the virus does not damage the cell or the patient, and that the therapeutic gene is expressed at levels sufficient to cure the cancer (see chapter 8 for a gene therapy primer).

Treatment Of Acyesis

Preparation method CN1245699 Fatigue-eliminating body-nourishing pill CN1245695 Deodorant oral liquor CN1242208 Special efficacy drug abstinence medicine CN1240644 Face mask for eliminating maculae and wrinkles and whitening skin and its preparation process CN1240142 Compound longshou soluble granules CN1207311 Health drink for preventing and treating common cold

Tips and Tricks

Balikian RV, Zimbler MS (2005) Primary and adjunctive uses of botulinum toxin type A in the periorbital region. Facial Plast Surg Clin North Am 13(4 583-90 Bulstrode NW, Grobbelaar AO (2002) Long-term prospective follow-up of botulinum toxin treatment for facial rhytides. Aesthetic Plast Surg 26(5) 356-9 Chen AH, Frankel AS (2003) Altering brow contour with botulinum toxin. Facial Plast Surg Clin North Am ii(4) 457-64 Kokoska MS et al. (2002) Modifications of eyebrow position with botulinum exotoxin A. Arch Facial Plast Surg 4(4) 244-7 Kokoska MS et al. (2002) Modifications of eyebrow position with botulinum exotoxin A. Arch Facial Plast Surg 4(4) 244-7 Le Louarn C (1998) Botulinum toxin and facial wrinkles a new injection procedure. Ann Chir Plast Esthet 43(5) 526-33

Ovids Grooming

In the new frescoed Roman art and portraiture set up for permanent public display on their household walls and floors, there were no lice, smells, wrinkles, disfigurements, or blemishes just delicately pencilled oval faces and graceful bodies, as neat and as perfect as their owners had intended themselves to be.

Upper Lip Drooping

The skin of the upper lip is very thin and lacks subcutaneous fat. The lack of additional support of this area together with extensive muscular movement of the main muscles may lead to pronounced wrinkles. The m. orbicularis oris is the major muscle of the lips. It has circumferential fibers that are responsible for the sphincter function of the mouth. The aim of the treatment is to prevent or reduce longitudinal wrinkles of the upper and lower lip. Treating the upper lip will inevitably lead to some functional impairment. Therefore it is preferable to treat patients with previous BNT-A experience. The treatment of the upper lip is a good preventive indication for BNT-A in younger women trying to avoid future longitudinal wrinkles. Before starting the treatment a careful case history is recommended as the m. orbicularis is involved in more than just forming wrinkles.

Aim of Treatment

Damage suffered to the facial nerve may produce deformities of varying degrees, resulting in aesthetic and functional disorders in such patients. The side of the face affected by facial paralysis presents common characteristics among all patients. On the surface of the skin, there are fewer wrinkles, due to the lack of muscular traction on the dermis the nasolabial fold becomes less evident, and there is a drooping of both the corner of the mouth and the brow. Depending on the extent of facial paralysis, and the time of onset, the aesthetic aspects may be affected to a greater or lesser extent (Fig. 6.2).

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