DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI 314-984-8331 WANTS YOU TO KNOW THAT BOTOX INJECTIONS FOR FACIAL LINES AND WRINKLES ARE EXTREMELY SAFE AND EFFECTIVE. IF YOU DON’T LIKE THE LINES OF YOUR FOREHEAD, “11″ WRINKLES BETWEEN YOUR EYEBROWS, YOUR CROWS FEET, OR YOUR “SMOKERS WRINKLES” AROUND YOUR MOUTH, YOU NEED TO CALL DR KOO AT 314-984-8331 AND SEE FOR YOURSELF IN 30 MINUTES WHAT YOU CAN AFFORDABLY ACHIEVE WITH NO DOWN TIME.

DR KOO IS EXTREMELY PRECISE ABOUT WHICH MUSCLES SHE INJECTS AND CAREFUL NOT TO USE ANY MORE THAN NECESSARY SAVING YOU COST AND MINIMIZING YOUR POSSIBLE COMPLICATIONS. IF YOU THOUGHT ALL THOSE MEDIA PERSONALITIES HAVE PERFECT FLAWLESS SKIN WITHOUT WRINKLES BECAUSE OF THEIR GENETICS OR GOOD LUCK, THINK AGAIN. THEY ALL HAVE THEIR FAVORITE PLASTIC SURGEONS, AND DR KOO WANTS TO BE YOURS.

THE FOLLOWING IS AN ARTICLE THAT SHE HOPES IS HELPFUL FOR YOUR EDUCATION ABOUT BOTOX AND ITS POSSIBILITIES OF SMOOTHING YOUR FACE WITHOUT SURGERY.

BOTOX (R) Injections to Improve Facial Aesthetics

Author: Pramit S Malhotra, MD, MS, Director, Malhotra Center for Plastic Surgery, PC
Coauthor(s): Daniel G Danahey, MD, PhD, Consulting Staff, Michiana Eye Center and Facial Plastic Surgery; Peter Hilger, MD, Professor, Department of Otolaryngology, University of Minnesota Medical School

Introduction

History

Botulinum toxin is best known to clinicians as a deadly poison produced by the Clostridium botulinum bacterium. Only within the past 2 decades have clinical applications for this toxin surfaced. Originally, applicability was found for botulinum toxin in the treatment of strabismus; however, this single indication has now grown into many. Currently, the Food and Drug Administration (FDA) has approved botulinum toxin A for blepharospasm, strabismus, cervical dystonia, and the aesthetic improvement of glabellar rhytides.

Common clinical uses

Currently, botulinum toxin is most commonly used in the management of hyperfunctional lines. Previously, hyperfunctional lines were the source of much consternation for those affected by them. These lines often caused patients to be misinterpreted as angry, anxious, fearful, or fatigued. In the past, plastic surgeons only had surgical options in their armamentarium, including excision or implantation of fat, collagen, or silicone. These procedures often provided minimal improvement and exposed patients to the risks associated with surgery. Injections of botulinum toxin A provide an opportunity to manage these hyperfunctional lines with minimal morbidity. The 3 most common sites for injection are the glabella, periorbital crow’s feet, and forehead areas.

Pathophysiology

Etiology of hyperfunctional lines

Hyperfunctional lines result from the contraction of the underlying facial musculature. The forehead is a complex of the frontalis muscle with insertions onto fibers of the procerus, corrugator, depressor supercilii, and orbicularis muscles. The frontalis muscle, responsible for the surprised appearance when acting unopposed, mediates elevation of the brow and is primarily responsible for horizontal wrinkles. Soft tissue laxity of the forehead and periorbital area causes brow ptosis and reflex contraction of the frontalis muscle to restore brow position, exacerbating forehead rhytides. Treatment of these rhytides with BOTOX® can increase brow ptosis.

The frontalis muscle can also be responsible for the appearance of scowling. However, the main agent responsible for the appearance of scowling is the corrugator muscle. The normal function of the corrugator is as a brow adductor, bringing the eyebrow medial and inferior. Chronic contraction of the corrugator results in deep vertical hyperfunctional lines between the eyes, sometimes referred to as a glabellar crease. The depressor supercilii muscle pulls the medial brow inferior and medially. The last muscle in this group is the procerus muscle, which overlies the nasal root. Contraction of the procerus results in a snout-nose appearance and a horizontal rhytid at the nasal root.

The anatomy of hyperfunctional lines in the orbit is intricate. Contraction of the orbicularis oculi muscle is primarily responsible for the clinically observed periorbital crow’s feet. The orbicularis oculi muscle is bordered superolaterally by fibers of the frontalis muscle and medially by the levator palpebrae muscle. Injection of this area requires special cognizance of adjacent musculature to avoid upper lid ptosis.

Pharmacology

The Clostridium botulinum bacterium produces 7 distinct toxins lettered A through G. All 7 toxins are antigenically distinct; however, toxin A is most familiar to clinicians. Botulinum toxin A (BOTOX®) causes paralysis by inhibiting acetylcholine release at the neuromuscular junction. This is accomplished in 3 steps. First, the toxin binds the nerve. Second, the toxin is internalized into the nerve. Third, the toxin is cleaved by internal proteolytic enzymes, and the degradation byproducts interfere with the normal process of vesicle fusion to the plasma membrane. This results in the inhibition of the exocytosis of acetylcholine.

The toxin requires 24-72 hours to take effect, reflecting the time necessary to disrupt the synaptosomal process. In very rare circumstances, some individuals may require as many as 5 days for the full effect to be observed. The dose of the toxin is measured as 1 standard unit, which is equal to the amount necessary to kill 50% of Swiss-Webster mice injected with that dose.

The effect of botulinum toxin lasts 8-12 weeks.

Indications

Current indications for BOTOX® injections include the following:

Contraindications

Contraindications to BOTOX® injections include the following:

• Pregnancy
• Lactation
• History of reaction to toxin or albumin
• Preexisting motor neuron disease (eg, myasthenia gravis, Eaton-Lambert syndrome, neuropathies)
• Age younger than 12 years
• Infection at the injection site
• Coincident administration of aminoglycosides can potentiate paralysis (relative contraindication)

Treatment

Patient Selection

Several prospective studies by Blitzer et al and Pribitkin et al have examined the effectiveness of botulinum injections for hyperfunctional lines. From these studies, certain characteristics of successfully treated patients have been identified. The ideal patients have thin skin, fine wrinkles, lines that are exacerbated by muscle contraction, and hyperfunctional lines that can be spread out with their fingers. Blitzer et al describe a “glabellar spread test” in which the physician is able to spread out the hyperfunctional glabellar lines to project the maximum benefit that a paralytic injection could achieve.

Candidates that have received minimal improvement from botulinum injections include those that failed the spread test, those with previous surgery near treated areas, those with thick skin or deep dermal scarring, and those with actinic skin changes. Facial lines resulting from the loss of dermal elasticity associated with aging are unlikely to respond to botulinum toxin injections. These areas are more appropriately treated with injectable fillers, which efface the static rhytides.

Treatment

Before the procedure is undertaken, a thorough history (including prior facial surgical procedures) and medication review are undertaken. Attention is focused on looking for those patients with contraindications as previously discussed. Preprocedure photographs are often taken by the individual surgeons’ photography studio. A close-up photograph that isolates the area of interest should be taken, as well as a full-face photograph. Photographs are taken at rest and during muscle contraction.

Physical examination concentrates on the identification of prior facial surgical sites, the assessment of the thickness of the skin, and the quality of the skin. Ahn et al note that thicker skinned patients often require higher doses. In addition, the accentuation of hyperfunctional lines with muscle contraction is noted as well as the ability to smooth out these lines with the spread test. Patients with larger muscles, such as men, also require higher doses of BOTOX®. Follow-up photographs are taken 3-4 weeks postinjection.

Botulinum toxin A (BOTOX®) arrives on dry ice and must be stored frozen at temperatures lower than -4°C. It comes in a 100-U bottle. One unit is defined as the median lethal dose in mice. The median lethal dose in humans is estimated at 3000 U. The toxin generally is mixed with 2.5 mL of 0.9% nonpreserved sterile saline solution, creating a concentration of 40U/mL.

Carruthers et al, in an outstanding consensus panel article, noted that panel members agreed that preserved saline could also be used. An insulin syringe with a 30-gauge needle works nicely for injection. The insulin syringe does not waste any of the solution in the hub of the syringe. Some clinicians are moving to 32-gauge needles, which demonstrate better patient tolerance.

The area of injection can be covered with topical anesthetic cream (eg, eutectic mix of local anesthetics [EMLA]) or can be anesthetized using ice. The solution then lasts up to 4 hours if refrigerated between injections, according to the manufacturer. Hexsel et al conducted a blinded multi-institution study and demonstrated that reconstituted BOTOX® retained its efficacy for up to 6 weeks when stored at 4°C.

Studies by Blitzer et al and Carruthers et al, and the BOTOX® Consensus Group provide some very reasonable dose suggestions, as follows:

• Forehead
  • A total of 10-30 U should be sufficient for this area. The patient is instructed to contract the areas of concern to demonstrate the approximate location of the hyperfunctional muscle. The injections are divided into 2- to 4-U injections. Most authors recommend that all injections be at least 1 cm above an imaginary line drawn horizontally between the middle portions of the eyebrows to avoid brow ptosis. An imaginary vertical line is drawn passing through the pupil for a reproducible reference point.
  • The first injection of 3 U is placed 1.5 cm above the superior bony orbital rim on this imaginary line. The second injection of 3.0-3.5 U is injected at a point 1.5 cm superior and 1.5 cm lateral from the first injection. The last injection uses the same dose but is injected 1.5 cm superior and 1.5 medial to the first injection. In effect, this creates a letter V. This set of injections is repeated on the opposite side. The injections are massaged in a direction away from the orbit.
• Glabellar region
• • This region can be divided into 2 areas. The superior-lateral region is the first area, and it is affected by the corrugator supercilii muscle. This muscle is responsible for the vertical furrow between the brows. Each muscle receives an injection of 10 U as follows: 5 U is injected into the medial portion of the muscle near its origin, and 5 U is injected in the mid portion of the muscle belly.
  • The central and inferomedial regions comprise the second area, and they are affected by the procerus muscle and depressor supercilii muscle. These muscles are responsible for the horizontal furrow at the root of the nose. A 6-U injection is placed into the middle of the procerus muscle belly, which is slightly off the midline (approximately 7 mm) and at the level of the superior orbital rims. The same injection is repeated on the opposite side. Then 3 U is injected into the depressor supercilii muscle, which is approximately 1 cm above the medial canthal tendon. Finally, 3 U then is injected on the opposite side. Great care must be taken not to inject the solution too deep, which may place BOTOX® into the orbit, causing an oculomotor paresis.
• Periorbital crow’s feet: A total of 12 U is used per side. Injections are divided into 3 U each. Using the patient’s right eye as an example, the first injection is approximately 1 cm lateral to the lateral canthus at the outermost portion of the bony orbital rim. This correlates approximately with the 10-o’clock position of the orbicularis oculi muscle (some authors feel that this injection provides a chemical brow lift of several millimeters in the lateral brow region). This is followed by an injection of 3 U at the half-past-9 position. The last 2 injections are placed at the half-past-8 and half-past-7 positions. Once again, the BOTOX® must be placed outside the orbital rim to avoid intraorbital complications.
• Nasolabial: This area has been difficult to inject and offers mixed results. Electromyograph (EMG)–guided injection of 2-3 U to paralyze the levator labii superioris alaeque nasi has demonstrated some success. The authors’ center does not use botulinum toxin in this area because of complications of upper lip paresis.
• Platysma: Platysmal bands can be treated with the direct injection of botulinum toxin into the concerning band. Once the band is identified, 5 U can be injected at 1-cm to 3-cm intervals along the vertical line created by the platysma. Some authors find these areas more amenable to surgical treatment.

Electromyograph monitoring

Many authors have chosen to perform their injections under the guidance of EMG monitoring. This technique involves using a 27-gauge (1.5 in) polytef-coated EMG needle connected to an EMG recorder by an alligator clip on its shaft. The patient is asked to contract the muscle in question. The injection is placed where the maximal EMG recording can be found within the muscle. This technique ensures that the injection is at the portion of the muscle that is contributing most to the hyperfunctional facial line. As these injections have become routine, many centers have obtained satisfactory results without EMG guidance. Many physicians use a readily available 30-gauge insulin syringe instead. However, EMG-guided injections remain a useful adjunct in patients who have residual function after their initial injection.

Reinjection

If a patient feels that little benefit was derived from the original injection, reinjection can be performed 1 week postinjection. However, 2-3 weeks postinjection is probably a more practical time for a return clinic visit. Generally, 2.5-5 U are used for reinjection. Reinjection strategies are still evolving. Once the patient has a satisfactory result, the next visit is at 2-3 months or when the patient requests another treatment.

Complications

The most feared complication is temporary paralysis of nearby facial musculature. Approximately 1-3% of patients may experience a temporary upper lid or brow ptosis; the most troublesome complication to the patient is upper lid ptosis. This results from migration of the botulinum toxin to the levator palpebrae superioris muscle. The ptosis usually lasts 2-6 weeks. It can be treated with apraclonidine (Iopidine, Alcon). This is an alpha-adrenergic agent that stimulates the Müller muscle and immediately elevates the upper eyelid. This treatment can usually raise the eyelid 1-3 mm. The treatment of 1-2 drops 3 times per day continues until the ptosis resolves.

Bruising can occur, particularly if a small vein is lacerated or a patient is taking aspirin, vitamin E, or NSAIDs. Ideally, patients should stop taking these products 2 weeks before the procedure. Headaches can occur after BOTOX® injections; however, in one study by Carruthers et al, this did not exceed the placebo group.⁶ This is thought to be due to the trauma of the injection and not something inherent in the toxin. In fact, botulinum toxin injections are extremely safe. To date, no significant long-term hazards of botulinum toxin injections have been identified in excess of placebo groups.

Future

The popularity of BOTOX® is unmatched in cosmetic surgery. The use and scope of botulinum toxin increases every year. Patients have shown a high degree of satisfaction with the procedure. Current research focuses on using BOTOX® as an adjunct to a myriad of surgical and ablative procedures.

Botulinum toxin A now has been used in significant numbers for 20 years. Its injection has proved to be an extremely safe strategy for selectively inducing muscle paralysis.

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON , ST LOUIS, MISSOURI hopes that this is helpful information. She will only suggest Botox for you if she feels it will be helpful and worthwhile for you based on your cosmetic goals for your face.

If you have one hour to spare, Dr Michele Koo, MD, Board Certified Plastic Surgeon, St Louis, MO, 314-984-8331 can fill your deep creases around your mouth, marionette lines and nasolabial folds to soften your face and remove 20 years. This will refresh your face and rejuvenate your look without surgery and down time in one hour and last up to 12-18 months.

Dr Koo uses Juvederm, Restylane, and various other fillers depending on how deep your creases are and the type of skin you have. The injectible fillers are hyaluronic acid which as a normal component in human skin.  Dr Michele Koo performs the injections herself and carefully evaluates the results and designs the perfect fill for you on all your subsequent follow-ups. She makes sure that you have individualized attention and care so as to perform the right filler injection just for you. She never allows an aesthetician or nurse to do the injection and feels extremely passionate that the results of the first injection will guide her to tailoring your treatment so that it is refined and subtle so you look refreshed and rested.

The following is an article by Dr Mary Lupo in the Plastic and Reconstructive Journal, January 2008. This should be helpful to let you know that BOTOX and JUVEDERM are extremely effective and safe and there are studies that actually look at the results and longevity of BOTOX and JUVEDERM.

With the baby boomer generation firmly ensconced in middle age and the ubiquity of botulinum toxin type A, nonsurgical facial rejuvenation is becoming increasingly prevalent. As this generation continues to age, products with greater therapeutic power to correct aging changes will be in growing demand.

A multicenter, double-blind, randomized, within-subject, controlled study was conducted comparing Juvéderm Ultra Plus hyaluronic acid filler with bovine collagen. A subset of subjects classified as having treatment for severe nasolabial folds is presented in this article. Subjects received Juvéderm Ultra Plus in one severe nasolabial fold and Zyplast collagen in the other nasolabial fold; up to two touch-up treatments were allowed at 2-week intervals. Nasolabial fold severity was evaluated every 4 weeks for 24 weeks using a five-point scale. Treatment site reactions and adverse events were also recorded. A complimentary treatment was offered at the end of the trial, with effectiveness evaluations just before retreatment and up to 48 weeks after repeated treatment for a subset of subjects.

Of the 87 subjects, most were female Caucasians, but all Fitzpatrick skin types were represented (36 percent types IV through VI). At 24 weeks, 96 percent of nasolabial folds treated with Juvéderm had maintained clinically significant correction, and 81 percent maintained the correction for 1 year or more. Results were similar for those subjects with follow-up through 48 weeks after repeated treatment. The median volume required for repeated treatment with Juvéderm was significantly less than that for initial treatment (0.7 ml versus 1.6 ml).

Juvéderm Ultra Plus provides correction of severe nasolabial folds through 1 year or more.

Continued in Next Blog

 

 

 

This blog will discuss 4 key processes of aging. These processes apply to the entire organism and every cell within it. Of course, they also apply to skin. However, skin is unique in that it is the organ that shields the interior of our body from the environment and all types of environmental assaults including solar damage, injury, pollution, and others. According to Dr Charlene DeHaven, Internal Medicine and Emergency Medicine specialist and head of the anti-aging program at the Kronos Clinic:

THEORY 1—OXIDATIVE STRESS

This theory is more commonly known as the free radical theory of aging. All cells need energy to perform their particular function. This energy is a very “hot” process and uses free radical generation to burn fuel. In this process, extra free radicals are created. These extra free radicals bounce around inside the cell, damaging all cellular structures they contact. Over a lifetime, these free radical “hits” gradually accumulate leading to a physiologic decline in structure and function. We label this decline “aging.” Skin cells being metabolically active are subject to the same free radical damage as other cells of the body. In addition, skin cells are damaged by energy packets of solar rays termed photons. Photons are themselves very high energy particles that are free radicals.

 

 

Depending on whether the sunscreen chosen is physical or chemical, these solar free radicals can be blocked or neutralized.  Antioxidants are helpful because they combine with free radicals and prevent the ongoing cascade of free radical damage. Only about one percent of oral antioxidants reach the skin so topical antioxidants are also critical.  Suboptimal health states such as severe burns,diabetes, critical illnesses, infections, vascular diseases, endocrine diseases and others are associated with excess free radical generation.

Smokers have huge amounts of free radicals floating about in their bodies. All life forms must deal with free radical damage from internal metabolism and from the sun. It is not surprising that plant substances usually have some amount of antioxidant activity. Some plant substances such as Centella asiatica are especially potent antioxidants. The three most active components of C. asiatica are madecassic acid, asiatic acid and asiaticoside. 

 

 

 

THEORY 2—INFLAMMATION

A certain amount of inflammation is required for health. Through its inflammatory response the body combats infections, clears away damaged tissue and heals sunburn and other oxidative processes. Excess inflammation results in accelerated rates of aging, scarring and destruction of normal tissue architecture. Free radical damage is well-known to trigger excess inflammation. The inflammatory response is elevated in those having higher levels of oxidative stress byproducts. Oleuropein is an anti-inflammatory substance found in the olive tree, Olea europaea. More anti-inflammatory activity is contained within the olive leaf than in other parts such as olive oil.

T

 

 

HEORY 3—GLYCATION

The process of attaching a sugar to a protein is called glycation. Oxidative damage is an intracellular process, i.e. occurs inside the cell whereas glycation is an extracellular process and occurs outside the cell. Glycation occurs in protein-rich tissues that contain large amounts of the protein collagen. Collagen-rich tissues include the skin, blood vessels, joints and lens of the eye. Glycated collagen is damaged collagen and less able to respond to physical stress by stretching. Glycated collagen has much less deformability and resilience.

Persons most subject to glycation have excess amounts of extracellular sugar (glucose). In this group are diabetics, the obese and the

elderly. These 3 groups are all relatively “insulin resistant;” that is, they do not respond to insulin in a normal way by moving glucose inside the cell. The excess extracellular glycose will glycate collagen and damage tissues containing large amounts of it. This illustrates why “tight glycemic control” or keeping glucose at a normal level is so important in preventing the complications of diabetes. Excluding diabetics, before the age of 40, the level of obesity is most important in determining the rate of glycation. After age 40, chronological age is more important than the amount of obesity. As we age, our ability to synthesize cellular products such as collagen decreases. This makes it more difficult for us to repair collagen damaged by glycation and other types of injury. Resveratrol is an anti-aging substance found within red wine that prevents vascular disease. Resveratrol is found in the outer covering of the grape seed. Grape seed extract also contains resveratrol. There are between 25 and 30 different theories of aging recognized by the NIH. Although some of these have much credible scientific support, they are still classed as “theories” because none have been irrevocably proven. There is no unified theory of aging. If there were, one ingredient in one skincare product would serve to treat aging skin. As it is, aging must be approached from the standpoint of multi-factorial causation with multiple ingredients and products. We are still learning about aging and how it affects the individual.

DNA is contained in the helical structure inside chromosomes in the nucleus of the cell. This DNA contains our genetic material and also directs the function of the cell in which it resides. A cell with damaged DNA cannot properly function and may even become cancerous. Increased DNA damage in skin occurs with photoaging and high oxidative stress. Not as much DNA damage is found with glycation because DNA is protected from glycation within the cell. Most glycation occurs extracellularly. Genetic defects such as Werner’s Syndrome illustrate the importance of DNA repair. Werner’s Syndrome is one of the progerias, the diseases manifesting greatly accelerated aging. Persons with Werner’s Syndrome lack the helicase enzyme required for DNA repair. In the teen years, these individuals look much like everyone else. By the age of 30, they look many, many decades older and have an accompanying high rate of disease and decreased lifespan. DNA is subject to free radical damage so antioxidants improve rates of DNA damage. Some growth factors such as EGF (Epidermal Growth Factor) or HGF (Hepatocyte Growth Factor) can direct the DNA of fibroblasts to synthesize more collagen. 

 

 

IMPROVING AGING RATE AND SURGICAL OUTCOME

Improving any of these 4 processes decreases the rate of aging and also improves surgical outcome. Individuals with excess free radical damage, glycation, inflammation or DNA damage have decreased healing capacity. Certainly, attacking the processes of aging in younger years is preferable. But even though “younger is better,” any time is better than never. This is illustrated by experiments on rodents the equivalent of 60 in human years. These rodents, prior to their rodent age of 60, lived a life full of stress, free radical damage and high carbohydrate diets. At 60, they were put on high doses of antioxidants. Their lifespan significantly increased even at this late age. Similarly, when anticipating a procedure, “sooner is better” for instituting good skincare practices. If begun just prior to surgery, then 2-4 weeks is a good estimate of the minimum time required to begin a skincare regime.