Botulinum toxin treatments have become the most sought after cosmetic procedure in aesthetic medicine. Though the extremely popular procedure can result in a more youthful appearance, adverse events can occur, the most common of which are brow and eyelid ptosis.
One of the main challenges when treating the upper-third of the face with botulinum toxin is how to treat the frontalis muscle in the forehead appropriately to smooth out wrinkle lines without creating a dropping of the brows.
"Correctly treating the frontalis muscle can be challenging. If injections are placed too low in the lower half of the muscle, you have a greater chance of brow ptosis," says Ronald Moy, M.D., president of the American Academy of Dermatology and professor at the David Geffen School of Medicine at the University of California, Los Angeles. "Physicians with less experience may often make the mistake of injecting too low, resulting in a dropping of the brow."According to Dr. Moy, one simple way to avoid this adverse event is to treat the upper half of the forehead/upper half of the frontalis muscle. Over time, the muscle will atrophy, weaken and drop due to the effects of gravity, particularly in patients over age 50.
Though a younger patient may be able to tolerate treating the lower half of the frontalis muscle better, an older patient will not, and errantly placed botulinum toxin injections will more frequently result in a more evident drooping of the brow.
EYELID PTOSIS, DRIFTING Though a rare occurrence, eyelid ptosis can also sometimes result when treating the upper-third of the face. This is due to drifting of the product, or it may result if injections are placed too close to the brow/eye area.
Drifting can occur if the physician injects too deep below muscle, placing the injection at the orbital rim. Here, botulinum toxin can drift along the bone and affect the muscles that innervate the eyelid, resulting in a ptosis. Less commonly, blurred vision can result if injections are placed too close to the lateral part of the eye where the extraocular muscles may be affected.
Should these adverse events occur, clinicians can treat with alpha-adrenergic drops such as Neo-Synephrine (phenylephrine hydrochloride, which will cause a constriction of the muscle and offer some temporary relief. These can be administered two to three times a day for many weeks or until the problem resolves.
According to Dr. Moy, the best policy when treating the upper face is to stay in a safe area and simply inject farther away from these ocular muscles.
"It is important to be very precise when treating the upper face and place the product right within the muscle. Also, one can try to refrain from performing multiple injections, which is commonly practiced in the glabella. Here, where some physicians may treat with seven or eight injections, I will only require two injections, achieving the same positive aesthetic outcome," Dr. Moy says.
PRECISION AND SYMMETRY Precision of injections is crucial when treating the upper-third of the face as well as keeping injections superficial, particularly in the eyelid area. When treating crows' feet, Dr. Moy says he will typically inject superficially, creating a small bleb with the product.
"Injection technique is crucial in this area of the face. It is also very important to aim the needle away from the eye when injecting, as this will very likely decrease the chances of getting a ptosis," Dr. Moy says.
Symmetry can also be an issue when treating the upper-third of the face with botulinum toxin because if unequal amounts of toxin are injected to each side of the face, one side may end up being higher than the other, or the lateral brow areas may appear uneven.
According to Dr. Moy, some patients may want a little elevation at the lateral brow area because this area tends to droop a little bit more. Therefore, Dr. Moy will often put a little botulinum toxin right at the end of the lateral brow or inject at the bridge of the nose and push it over and massage it to the medial canthus. This will raise the middle part of the brow and result in a good middle-brow elevation.
"It is important to have a detailed discussion with patients and clearly understand their specific aesthetic needs and desired aesthetic goals. When addressing the brow and forehead areas, you must listen to the patient longer than you would usually for any other area, as cosmetic goals can vary greatly from patient to patient," Dr. Moy says.
Disclosures: Dr. Moy has been paid to give lectures on the use of all neurotoxins by Paradigm, a continuing medical education company. He also performed a study on Dysport for Inamed about six years ago.