This book, containing more than 200 cadaveric photos and 200 illustrations, aims to familiarize physicians practicing botulinum toxin type A (BoT-A) and filler injection with the anatomy of the facial mimetic muscles, vessels, and soft tissues in order to enable them to achieve optimum cosmetic results while avoiding possible adverse events. Anatomic considerations of importance when administering BoT-A and fillers are identified and in addition invaluable clinical guidelines are provided, highlighting, for example, the preferred injection points for BoT-A and the adequate depth of filler injection. Unique insights are also offered into the differences between Asians and Caucasians with regard to relevant anatomy. The contributing authors include an anatomist who offers distinctive anatomic perspectives on BoT-A and filler treatments and three expert physicians from different specialties, namely a dermatologist, a plastic surgeon, and a cosmetic physician, who share insights gained during extensive clinical experience in the use of BoT-A and fillers.
Because no single modality can be used to address all areas effectively and safely, consensus guidelines on facial rejuvenation have been developed that discuss combined techniques for different parts of the face, namely, the upper, mid- and lower facial thirds. Most guidelines have also provided specific approaches for subjects of various ethnicities.[2,4,5] It is common to see the use of different combinations of injections (e.g., fillers, toxins) or energy devices (e.g., ultrasound) along with other modalities. The aim of using these techniques is to relax, resurface, and volumize facial tissue, and ultimately, to achieve the most harmonious and most natural-looking facial rejuvenation possible.[2] Hyaluronic acid (HA) fillers have now become the most common filler of choice due to their versatility, ease of use, and because they are well tolerated by most patients.[6]
Clinical Anatomy of the Face for Filler and Botulinum Toxin Injection free download
Although botulinum toxin is often believed to be the mainstay of wrinkle correction, it is not recommended for all types of wrinkles. Specifically, it is only useful for the correction of dynamic wrinkles such as forehead lines, glabellar lines, periorbital lines (canthal), wrinkles seen on the dorsum of the nose, and fine lines around the lips. Because the effect of botulinum toxin is relatively poor for furrows, such as the deep nasolabial folds and marionette lines, fillers are mainly used to improve the appearance of these grooves. Botulinum toxin is also not recommended in some dynamic wrinkles such as the transverse infraorbital wrinkles and zygomatic wrinkles due to the risk of worsening the aesthetic appearance of the area [Figure 1].[19]
Abstract:The masseter is the most targeted muscle when treating hypertrophy to produce a smooth face shape. Compensatory hypertrophy is a well known clinical sequela that occurs in botulinum neurotoxin (BoNT) treatments and is limited to the lower part of the masseter. Based on the masseteric hypertrophy procedure, which targets a confined area, we predicted the possibility of compensatory hypertrophy occurring in the upper part of the masseter. If the patient complains about an unexpected result, additional injections must be performed, but the involved anatomical structures have not been revealed yet. The aim of this study was to identify the morphological patterns of the masseter. Deep tendons were observed in most specimens of the upper part of the masseter and mostly appeared in a continuous pattern (69.7%). The superficial and deep tendons could be classified into a simply connected form and forms surrounding part of the muscle. In 45.5% of cases there were tendon capsules that completely enclosed the muscle, which can interfere with how the injected toxin spreads. Interdigitation patterns in which the tendons could be identified independently between the muscles were present in 9.1% of cases. The present findings provide anatomical knowledge for use when injecting BoNT into the masseter.Keywords: superficial part of masseter muscle; compensatory hypertrophy; botulinum neurotoxin type A injection; masseteric hypertrophy treatmentKey Contribution: The additional injection of BoNT should be performed in consideration of the anatomical structure, in case of an unexpected result due to long-term treatment. The tendon structures are particularly important for the additional injection of the compensatory hypertrophy treatment, but clinicians should consider this structure when they approach all kinds of non-invasive treatment of the masseter.
Abstract:The aim of the study was to propose a more efficient and safer botulinum toxin type A (BoNT-A) injection method for the masseter by comparing the conventional blind injection and a novel ultrasonography (US)-guided injection technique in a clinical trial. The 40 masseters from 20 healthy young Korean volunteers (10 males and 10 females with a mean age of 25.6 years) were included in this prospective clinical trial. The BoNT-A (24 U) was injected into the masseter of each volunteer using the conventional blind and US-guided injection techniques on the left and right sides, respectively, and analyzed by US and three-dimensional (3D) facial scanning. One case of PMB (paradoxical masseteric bulging) was observed on the side where a conventional blind injection was performed, which disappeared after the compensational injection. The reduction in the thickness of the masseter in the resting state differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 12.38 7.59% and 17.98 9.65%, respectively (t(19) = 3.059, p = 0.007). The reduction in the facial contour also differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 1.95 0.74 mm and 2.22 0.84 mm, respectively (t(19) = 2.908, p = 0.009). The results of the study showed that the US-guided injection method that considers the deep inferior tendon by visualizing the masseter can prevent the PMB that can occur during a blind injection, and is also more effective.Keywords: paradoxical masseteric bulging; ultrasonography guided injection; botulinum neurotoxin type A injection; compensatory hypertrophyKey Contribution: A US-based evaluation provides many clues about the anatomy of the masseter and the clinical application of BoNT-A. US-guided injection method that considers the DIT by visualizing the masseter can prevent the PMB that can occur during a blind injection, and is also more effective.
BOTOX Cosmetic is contraindicated in the presence of infection at the proposed injection site(s) and in individuals with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation.
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junction disorders (eg, myasthenia gravis or Lambert-Eaton syndrome) should be monitored when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise from onabotulinumtoxinA (see Warnings and Precautions).
Treatment with BOTOX and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. In most cases, this is a consequence of weakening of muscles in the area of injection that are involved in breathing or oropharyngeal muscles that control swallowing or breathing (see Boxed Warning).
Results: Neurotoxins and fillers are characterized by unique physical characteristics that distinguish each product. This results in subtle but important differences in their clinical applications. Specific indications and recommendations for the use of the various neurotoxins and soft-tissue fillers are reviewed. The discussion highlights refinements in combination treatments and product physical modifications, according to specific treatment zones.
Justinus Kerner had discovered toxin from rotten sausages and reported in 1829. In 1897, Professor Emile Pierre van Ermengen from Belgium discovered anaerobic bacteria capable of forming spores from salted pork meat and from a cadaver infected with botulinum toxin (botulism) [5]. Since then, this bacteria is named as Clostridium botulinum, and exotoxin protein BTX-A, which this bacteria expresses was named after the bacteria [6]. With the outbreak of World War I and World War II, people refined botulinum for weaponization, and scientists started to research using refined BTX-A to study its mechanism of action, and its action on the contracting mechanism of muscle. In 1973, Alan B. Scott was the first to use BTX-A for treating strabismus. Since 1979, as the FDA (American Food and Drug Administration) approved BTX-A for treating strabismus; it is being widely used for various treatment purposes [1]. After then, clinical studies were performed on blepharospasm or hemifacial spasm, and in 1989, the FDA finally approved its application in these diseases as well. 2ff7e9595c
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