YOUNG ADULTS WANTING BOTULINUM TOXIN COSMETIC TREATMENTS
Injectable neurotoxins continue to be a staple of aesthetic practices worldwide, but little is known about the use of this therapy in younger patients.
A recent review investigation1 appearing in the Journal of Cosmetic Dermatology sheds light on this issue and calls for more research to fill the gap. ‘’When I started practicing 15 years ago, some younger patients wanted wrinkle reduction, but the patient was commonly aged 50 and older,” explained author Alain Michon, MD, medical director of The Ottawa Skin Clinic/Project Skin MD in Ottawa, Ontario, Canada. “There has been a recent shift in the patient demographic with younger patients seeking injectable neurotoxin, but also in the treatment paradigm with prevention in mind, rather than correction.”
Despite this shift, there remains a lack of high-quality research on use of injectable neurotoxins in this patient demographic. In fact, Dr. Michon could only find four papers that fit his basic criteria of age range (under 41 years) and therapy choice (neurotoxin injections for facial cosmetic correction only, no combination therapies). “Only two studies were post hoc analysis of randomized controlled trials, the other two were observational studies,” he explained.
In addition to reviewing the existing research, Dr. Michon also conducted a cross-sectional online survey of aesthetic practitioners to get a sense of current practices. “There is always pressure from manufacturers to adhere strictly to recommended dosages, but we all know that, in practice, this does not happen. As a community, we rely on the science, but we also rely on our clinical experience to determine safe and effective dosages, partly aligned with patient desires for correction.”
According to Dr. Michon, the findings suggest that injectable neurotoxin is effective, as expected, but there is much to be learned from the dosing patterns and motivational factors among the younger population. “Our work showed that this population tends to receive smaller doses for the common injection targets and are looking for prevention, rather than correction,” he said. “Furthermore, they want to avoid an unnatural or ‘frozen’ look.”
“We are also seeing a movement toward more neurotoxin microinjection for management of skin quality, called ‘microtox,’ which understandably appeals to the younger population because of their stated goals,” he added. “As practitioners, we need to have a total consultation in an effort to understand the patient’s aims. More study of this would be revealing.”
Dr. Michon also noted that patient goals are not always considered in research. “We see studies that determine efficacy of dosages –the issue of dose-response – but not how this may correlate with what the patient was hoping to achieve. There is a psychosocial aspect in this field of medicine that is very important to account for, especially as we trend toward more holistic approaches in the industry.”
This may help practitioners improve their treatment planning as they attempt to better individualize therapy, but certainly more research is needed. “There are weaknesses inherent to injectable neurotoxin research due to the methodologies and dosage unit differences, but in this case, we are further held back because there is so little research on the specific subject which, given current trends, we should rectify,” Dr. Michon explained.
1. Michon A. Botulinum toxin for cosmetic treatments in young adults: An evidence-based review and survey on current practice among aesthetic practitioners. J Cosmet Dermatol2022; epub ahead of print.
Editor’s Note: The original article Botulinum Toxin for Cosmetic Treatments in Young Adults: An Evidence-Based Review and Survey on Current Practice Among Aesthetic Practitioners, is open access and available online at: https://onlinelibrary.wiley.com/doi/full/10.1111/jocd.15513
ELEVATING THE DORSUM FOR ETHNIC RHINOPLASTIES
Augmentation rhinoplasty, while less common, is more prevalent in ethnic populations where the bridge of the nose is lower, and the tip either does not project adequately and/or tends to be wide.
“For these populations, surgical augmentation makes the nose narrower and more defined-looking in the frontal view and contribute to what the patient perceives as an overall improved facial appearance,” explained plastic surgeon Dean Toriumi, MD, of Toriumi Facial Plastics (Chicago, Ill.).
“The problem is that many current techniques rely on artificial materials; these may become infected, or cause deformity or thinning of the skin over time,” said Dr. Toriumi. “Using autologous material may be intimidating to some physicians but is more desirable, and easily within the scope of what most plastic surgeons can learn to do comfortably, which I believe is worth the effort.” To help patients –and their surgeons – achieve optimal results, Dr. Toriumi published his technique1 in Facial Plastic Surgery & Aesthetic Medicine.
The cornerstone of Dr. Toriumi’s technique is that unlike many dorsal onlay grafts where new material is placed on top of the nasal dorsum, the bridge of the nose is surgically separated from the underlying septum, and harvested cartilage is placed underneath to elevate it – a key advantage. “This lifts the entire bridge of the nose, which simultaneously preserves and works with the patient’s natural facial contours,” he said. “Each individual’s dorsal aesthetic lines, as they are called, have a unique person-al contour which is very difficult to recreate, so why not try to preserve them?
“When you use the more traditional graft above the bridge, the graft may shift or change shape after a while, or the skin may thin, any of which can create an unnatural appearance,” he added.
According to Dr. Toriumi, his technique is a logical extension of a technique known as dorsal preservation. “Essentially, dorsal preservation means cutting bone below the bridge to push the ‘bump’ of the nose down rather than chopping the top of that hump away in patients with a narrow, tall nose. The goal is to preserve the patient’s natural facial contours, letting what is already there provide what would otherwise need to be reconstructed by the surgeon.”
While this technique is beginning to gain traction in the U.S., it is very popular in Europe, South America and Mexico. “I have been using this technique for three years and I find it very effective, so I thought that if we are completely freeing up the bridge, why not elevate it from below for augmentation cases? After all, if your house is shifting you often need to raise and shore up the foundation, not build on top of it or replace the roof with a new one.”
The procedure, and paradigm, of dorsal preservation is less commonly understood in the U.S. “This can be intimidating to some, but if you embrace the dorsal preservation procedure, the bone cuts become familiar quickly, as do the ways in which the cartilaginous vault can be manipulated effectively,” noted Dr. Toriumi.
The patient’s own rib cartilage is an ideal graft. “The rib cartilage is best, not septal or ear cartilage which would not be strong enough to support the bone from below,” he explained. “The graft must sufficiently support the bridge in its new position for the lifetime of the patient.”
A one-inch incision, typically on the right side of the chest, will provide access to the ribcage where a 6 cm to 7 cm segment of costal cartilage can be obtained. “If the patient’s cartilage is softer, a costochondral rib bone segment is best but usually I prefer, denser, more calcified costal cartilage from the seventh rib. A bony portion should be left to provide an ossifying interface to fix the graft properly.” The strength of the graft can be assessed before harvest using a 1.5 inch, 22-gauge needle.
While cadaver rib is a possibility, Dr. Toriumi always prefers an autologous graft. “Going to a secondary site is more complicated and lengthens the procedure, but to me it is worth it to obtain a superior autologous graft.”
Computer imaging can help the physician and patient visualize possible outcomes and make specific choices such as positioning of the middle vault, ideal tip projection, dorsal width and radix elevation, according to Dr. Toriumi.“We often use chin projection as a guide to how much tip projection will be acceptable.”
He added that other procedures such as chin or glabellar augmentation may be called for in some cases.
Also, the utility of the technique is not limited to specific ethnic groups. “This can be used in patients that have a low dorsum or what we call a saddle nose deformity. In fact, close to half of the cases I have treated were caucasian patients with either some natural or post-traumatic deformity, but I believe this will catch on more with the ethnic patients seeking this kind of correction.”
1. Toriumi, DM. Subdorsal cantilever graft for elevating the dorsum in ethnic rhinoplasty. Facial Plastic Surgery &Aesthetic Medicine.2022;24(3):143 – 159.
Editor’s Note: The original article Subdorsal Cantilever Graft for Elevating the Dorsum in Ethnic Rhinoplasty, is open access and available online at: https://pubmed.ncbi.nlm.nih.gov/35724256/