There's more than one way to apply minimally invasive treatments to any given patient both safely and successfully, say experts who discussed how they would approach several typical cases during Vegas Cosmetic Surgery 2011 in June.
From neuromodulator dosing to filler choices, "There's room for a lot of individual preference. That's the art of it — there is no right answer," says Corey Maas, M.D., a San Francisco facial plastic surgeon.
BROW PTOSIS, VOLUME LOSS In the case of a 77-year-old female patient with brow ptosis who chose botulinum toxin injections over surgery, Gary Monheit, M.D., says he'd begin by examining for brow asymmetry. To that end, "I always have my patients animate, to see whether the wrinkles she has in her glabella, forehead and crow's feet will respond to toxins — are they dynamic?" Dr. Monheit is associate clinical professor of dermatology and ophthalmology, University of Alabama, Birmingham.Hema Sundaram, M.D., a Washington dermatologist and cosmetic surgeon who actually treated the aforementioned patient (see images, page 21), says the key was understanding the complex relationship between her facial muscles, both when contracted and relaxed. "I do address the dynamic aspects by relaxing muscles in animation," she says, "but I also consider it crucial to rebalance muscles in repose. I've found that patients are often very focused on how they look at rest when they look in a mirror. We can improve that significantly through advanced techniques with Dysport (abobotulinumtoxinA, Medicis), Botox Cosmetic (onabotulinumtoxinA, Allergan) or Xeomin (incobotulinumtoxinA, Merz Aesthetics). We're also starting to understand that we can reshape the whole face with neuromodulators alone, and also address pre-existing problems, such as this patient's partially compensated right eyelid ptosis."
He also says he'd suggest perioral botulinum toxin injections for the patient's crow's feet and fine lines in her lower eyelids. "Do a snap test first to make sure that she's got resiliency to handle some toxin in the lower lid," he says. If that's the case, "I've found that microinjections of botulinum toxin on the orbital rim, and one small injection (one or two units of Botox) directly under the pupil will soften the fine wrinkles in that area. There's a myth that people over 65 don't do well with toxins. In my experience, they do very well."
Because the patient's corrugator on the left side appeared more active than the right, says Amir Moradi, M.D., a San Diego facial plastic and reconstructive surgeon, "I believe she would benefit from treatment of the depressor supercilii of the left corrugator. Cosmetically, that's going to help her achieve better symmetry."
Regarding the patient's lower face, Dr. Moradi says, "I would look at her dynamically to determine whether I should treat the orbicularis oris. I don't believe she needs treatment in the depressor anguli oris (DAO)." However, he adds, the patient may benefit from midline platysmal botulinum toxin injections.
Ultimately, Dr. Sundaram injected the patient's frontalis with 50 units of Dysport — keeping the injection points confined to the upper half of the forehead. "This is a good strategy to avoid compromising the compensation provided by her right frontalis, which would worsen the patient's pre-existing eyelid ptosis," Dr. Sundaram says.