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Shifting cosmetic goals, treatment advances allow for fewer complications


Botulinum toxin injections are more popular than ever in aesthetic medicine and have become a staple in the everyday armamentarium of the cosmetic physician.


Miami Beach, Fla. - Botulinum toxin injections are more popular than ever in aesthetic medicine and have become a staple in the everyday armamentarium of the cosmetic physician.

Beyond a requisite in-depth knowledge of the local anatomy, one expert says understanding the patient’s cosmetic goals as well as a matured aesthetic vision consistent with the times is crucial in achieving superior aesthetic outcomes.

Since the inception of cosmetic botulinum toxin treatments, says Marina Landau, M.D., it has become widely known and accepted that the cosmetic treatment is considered safe, and that the complications associated with the treatment are more of an aesthetic issue and less of a functional one.

“What we have learned from our years’ experience is that life-threatening complications from the treatment are extremely rare and do not exist as such. However, cosmetic complications do exist in that our cosmetic vision of how our patients should look has changed,” says Dr. Landau, dermatology and cosmetic dermatology immediate past-president, Israel Society for Dermatologic Surgery, Herzlia Pituach.

According to Dr. Landau, the pioneering physicians of cosmetic botulinum toxin treatment decades ago did not have the benefit of literature regarding complications because they were the first generation of physicians who started using the treatment cosmetically in patients. What has changed, Dr. Landau says, is the aesthetic view and how physicians use the botulinum toxin injections to create a more youthful and vibrant-looking patient.

“Our aesthetic vision has been changed so much that currently, I am showing my best cases of the previous era as cosmetic complications. Through our years of experience, our aesthetic and artistic sense has matured and we have learned how a cosmetic patient should look in terms of natural and youthful aesthetic outcomes,” Dr. Landau says. “So, the ‘complication’ so to say, is a question or change in the aesthetic.”

Shifting goals

In the past, cosmetic botulinum toxin injections were used to simply paralyze the targeted facial muscles without any particular aesthetic finesse or creative vision, which would often lead to a mask-like appearance of the patient.

One of the typical stigmata of early botulinum toxin treatments, Dr. Landau says, was the “Mephisto-look” following a browlift with the toxin. Here, the central part of the eyebrow at the corrugator supercilii would be paralyzed, causing a compensation of the lateral part of the frontalis muscles, creating a hyperelevation of the eyebrow particular at the center of the brow.

“While we were paralyzing these muscles, other facial muscles would over-compensate the paralysis, resulting in a new balance of muscular activity of the face,” she says. “Today, the primary goal of treatment is not to paralyze the patient’s targeted facial muscles per se, but instead to relax them and create a natural balance of the musculature, resulting in a more relaxed, softer and natural looking appearance in our patients.”

Natural appearance

This new balance of facial muscles, Dr. Landau says, is all about creating a natural looking balance between the depressors and elevators of the facial muscle groups in a particular region of the face.

In creating this “new balance,” Dr. Landau says it is paramount that the clinician injects the appropriate amount of toxin in a given muscle, measured according to the cosmetic correction to be made.

Using the appropriate amount of toxin at the correct injection site, as well as fewer injection points can also be instrumental in helping to avoiding potential functional complications that could result from botulinum toxin treatment, Dr. Landau says.

Eyelid ptosis used to be one of the most common functional complications in the early days of botulinum toxin treatments, she says. Now that physicians have learned where to place the correct injection site, however, this complication has become uncommon.

“It must not be forgotten that every patient’s face is different and there is no single injection treatment protocol that will fit every patient. Therefore, we need to analyze each face individually in order to establish what are target is, communicate and convey the right aesthetic ideas to the patient, and individualize treatments accordingly. This can help lead to the best results with botulinum toxin,” Dr. Landau said.

Disclosures: Dr. Landau reports no relevant financial interests.

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