The 2016 Global Aesthetic Consensus Guidelines as published in the Journal of Plastic and Reconstructive Surgery include the following trends for the use of botulinum toxins:
- There has been a paradigm shift from muscle paralysis to neuromodulation with a more natural look the modern ideal. Lower dosing is preferred, e.g. of the forehead and lower lateral canthal points.
- The ideal is an individualised, pan-facial approach with careful analysis of target muscles in the context of adjacent muscles as well as associated hard and soft tissues. Worldwide there is now more equal use of fillers and toxins in all facial areas (upper, mid- and lower face).
- The trend is towards treating adjacent muscle groups in conjunction (e.g. glabella and lateral canthal) in order to utilise lower dosages per area, reduce recruitment from adjacent areas and reduce unwanted side-effects.
- There is a universal preference for the use of constitution with preserved saline in order to minimise injection discomfort, with efficacy found to be similar to that when utilising unpreserved saline.
- The importance of selecting age-appropriate goals is underscored.
- The worldwide reported incidence of lid ptosis after glabellar toxins is 2,5 % and decreases with experience of the injector. Suggested guidelines include not injecting lower that 1,5 cm above the bony orbital rim . Lid ptosis may be treated by using aproclonidine eye drops to stimulate the Muller’s Muscle, which is adrenergic and not cholinergic.
- Lid ptosis needs to be clinically differentiated from brow ptosis for which there is no active treatment other than waiting for the effect to wear off.
- The use of an intra-cutaneous microbolus technique is being widely used in areas where the spread of effect needs to be limited (e.g. forehead)
- There are 5 documented glabellar contraction patterns. The individual patient’s needs should be assessed before planning the treatment points. These patterns are based on whether there is approximation, depression or elevation of the brows (see slide) and may differ between the two sides of the brow.
De Almeida et al. Glabellar Contraction Patterns: A Tool to Optimise Botulinum Toxin Treatment Dermatol Surg 2012 ; 38:9 1506 – 1515
Methods of minimising injection pain include use of:
- Preserved saline
- Smaller gauge needle (e.g. 31 G for peri-ocular areas)
- Intra-follicular injection
- Lower injection volume
- Pre- cooling the area
- Distraction techniques
- Thorough practical knowledge of facial anatomy and the origins and insertions of muscles helps us to better understand the importance of placement and the danger of product migration to adjacent muscles.
- A botulinum toxin may be refrigerated and used for 4 to 6 weeks after reconstitution. If inadvertently frozen, it need not be discarded.
- The individual muscle strength and contraction pattern (kinetic, hyperkinetic, hypertonic: as described by
M de Maio) may influence the duration of effective treatment.