Hyperfunctional Lines Research Articles

Botulinum toxin for the treatment of hyperfunctional lines of the forehead.

Background:In the 21st century, we live longer and a more active life. However, while our adult longevity continues to extend, society does not welcome a tired and aged appearance. We wish to continue to look as young as possible. Most facial rejuvenation techniques such as surgery and injection of collagen, silicone, or autogenous fat do not address the fact that these lines are functional, i.e. they do not target the cause of hyperfunctional lines: the underlying facial mimetic musculature.Aim:To find the efficacy of Botulinum toxin for the treatment of hyperfunctional lines of the forehead.Materials and Methods:The present study consisted of 25 subjects in the age group of 25–65 years with forehead wrinkles, who visited the Department of Oral and Maxillofacial Surgery, CIDS, Virajpet. The materials used for Botulinum toxin treatment were Botulinum toxin A, a standard freezer, sterile saline solution, alcohol swabs, and insulin syringes with 30 gauge needles.Results:Of the 25 patients, 21 patients showed satisfactory improvement of their hyperfunctional facial lines within 72 h. Maximum improvement was noted in the age group of 25–40 years, while the older age group of 50–65 years showed less improvement. Maximum improvement was seen in type 5 skin, followed by type 4 and type 3 skin. Type 2 skin showed the least improvement.Conclusion:We conclude that Botulinum toxin A is a safe and efficacious method of nonsurgically eliminating hyperfunctional facial lines of the forehead in the aesthetic patient for a period of 4–6 months.

Neuromodulators: Available Agents, Physiology, and Anatomy

Neuromodulators have risen to the forefront of aesthetic medicine. By reversibly relaxing target muscles, neuromodulators exhibit their effect by softening hyperfunctional lines. An understanding of their physiology, relevant facial anatomy, and current agents is imperative for a successful aesthetic practice.

Office‐Based Facial Plastic Procedures for Otolaryngologists

Program Description: The modern otolaryngologist has had residency-based, and in many cases, advanced fellowship training in a wide spectrum of facial plastic and reconstructive procedures to correct congenital-, acquired-, and aging-related deformities. Due to advances in technologies, there has been an increase in the ability to offer patients a variety of effective and minimally invasive interventions in the office setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge for which patients seek consultation. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of hyaluronic acid–based agents created a significant increase in acceptance and demand for filler substances by patients. More recently approved and soon to be approved fillers promise to increase the application. Laser and light technologies, including laser hair removal, offer intervention for an increasingly large number of clinical issues including the treatment of wrinkles, hyperpigmentation, cutaneous vascular lesions, rosacea, unwanted hair, and other aging-related skin conditions. Finally, although not representing new technology, but instead low-cost effective treatments, the practitioner will find the availability of skin care services, particularly the use of various chemical peeling agents, to be a useful adjunct in the office setting. The purpose of the miniseminar is to present an up-to-date review of safe, effective office-based procedures that the otolaryngologist may have available to patients in their office. The presentations will review the pertinent pharmacology, physics where applicable, and anatomy. Technique, preoperative and post procedure issues will be discussed. The clinical photo-rich presentations will demonstrate technique and patient selection. The prevention and management of complications will be reviewed. This miniseminar will update the attendees that have previous training in these procedures and serve as an introduction to those that are exploring these procedures. Educational Objectives: 1) Learn the indications and techniques for cosmetic botulinum toxin injections. 2) Learn the indications and techniques for facial filler injections. 3) Learn the indications and techniques for chemical peels, lasers, and light-based devices.

Office Based Facial Plastic Procedures for Otolaryngologists

Program Description: The modern otolaryngologist has had residency-based, and in many cases, advanced fellowship training in a wide spectrum of facial plastic and reconstructive procedures to correct congenital-, acquired-, and aging-related deformities. Due to advances in technologies, there has been an increase in the ability to offer patients a variety of effective and minimally invasive interventions in the office setting. Among these interventions, the use of injected botulinum toxin has become common in the treatment of rhytids, hyperfunctional lines, and facial dystonias. The treatment of skin and subcutaneous contour deformities is also a common challenge for which patients seek consultation. Although previously the materials used for correction were limited in number, there has now been an increasing number of widely used and newly introduced materials made available to the practitioner. The introduction of hyaluronic acid–based agents created a significant increase in acceptance and demand for f...

Safety and Efficacy of Botulinum Toxin Therapy in Otorhinolaryngology: Experience From 1,000 Treatments

The objective of this study was to analyze the safety and efficacy of botulinum toxin (BTX) therapy in a series of 1,000 treatments on 261 consecutive patients at the University Department of Otorhinolaryngology-Head and Neck Surgery, Cologne, Germany. A prospective computer database was analyzed, and all patient charts were reviewed retrospectively. In doing so, the main focus was put on patient characteristics, treatment methods, efficacy, unwanted side effects, and reinjection rate. A total of 16 different indications were treated with BTX belonging to the categories of focal dystonias, focal hyperhidrotic syndromes, and cosmetic dermatology. The overall morbidity was 1.3%, exclusively consisting of minor side effects. These were all reversible and mostly caused by paralysis of adjacent musculature. We did not observe any severe complications. Three (1.2%) patients developed a secondary nonresponse to BTX type A (BTX-A). Their treatment was continued with BTX type B. In 2.8% of treatments, patients thought the clinical effect was weak and returned for reinjection within 4 weeks after the first treatment. The experience from the largest patient series known confirms that BTX-A injections are the therapy of choice for many forms of focal hyperhidrotic syndromes, focal dystonia, and hyperfunctional lines. It is an effective and safe treatment with only minor side effects. For optimal individual results, a thorough documentation of each treatment is necessary. Dosages should be as low as possible to reduce the probability of a patient developing a secondary nonresponse.

Esthetic and cosmetic dermatology

The field of esthetic and cosmetic dermatology has gained remarkable interest all over the world. The major advantage of recent years is the high scientific levels of the most significant new developments in techniques and pharmacotherapy and other nonsurgical approaches. The present paper reviews selected fields of interest under this view. Sexual hormones are involved in the aging process of men and women. Skin function, in particular the epidermal barrier, is affected by a loss of endocrine activity. Hormone replacement therapy has only recently been introduced in treatment of aging males. This is an area of gender-medicine in dermatology with a strong well-aging attempt. Botulinum toxin therapy for hyperfunctional lines has become not only well-established but evidence-based medicine on its highest level. Recent advantages were gained in objective evaluation and monitoring the effect. Digital imaging techniques with various facets have been introduced to assess the achievements of treatment in the most objective way. This may become an example for other techniques as peeling, laser therapy, or radiofrequency in esthetic and cosmetic dermatology. Botulinum toxin has become a valuable tool for brow lifts. Details of the technique are discussed. Cellulite is a strongly female gender-related condition. During the past decades numerous treatments had been recommended but only recently a more critical scientific approach led to improvements in therapy of this common and disfiguring condition. Three major approaches are developed: (a) skin loosing with techniques such as subcision, (b) skin tightening with radiofrequency and other approaches, and (c) improving circulation in blood and lymphatic microvasculature using both physical treatments and pharmacotherapy. The last two chapters are devoted to body sculpturing by lipotransfer and lipolysis. Lipotransfer for facial or body sculpturing has a history of about 100 years. Nevertheless, recently the role of adult stem cells in adipose tissue has gained much interest. By optimizing the harvesting, storage, and transplantation of adipose tissue, remarkable long-standing results have been obtained. Here the present authors will focus on midface contouring, where lipotransfer competes with dermal fillers. Lipolysis is another effective tool in body sculpturing. The present authors will focus on recent advances in laser-assisted lipolysis for delicate body sculpturing in the submental region but also for gynecomastia abdominal region, flanks, and hips. In conclusion, esthetic and cosmetic dermatology has become a scientific-based subspeciality of dermatology with evidence-based treatments and a great variety of high-tech approaches to provide more effective, more selective, and safer therapeutic options.

Botulinum toxin—physiology and applications in head and neck disorders

This article is structured around a literature review that was carried out using Ovid and Medline with the key words "botulinum," "toxin," and "ENT." Botulinum toxin has been used safely in humans for more than 20 years. The effects are transient, such that treatments are required to be repeated at intervals. Its application to ENT provides a useful tool to treat dystonia, autonomic dysfunction, facial nerve paresis, and hyperfunctional lines. It may also be of benefit in laryngeal rebalancing and the treatment of headaches. Further research is being carried out and new indications for treatment with botulinum toxin may include sialorrhea and rhinorrhea.

Botulinum toxin for periocular lines: the single‐injection technique

Botulinum is a well established treatment for facial wrinkles and hyperfunctional lines, including those at the periocular area. To illustrate a simple periocular injection technique. It differs from the usual one since it is a single injection, instead of several. Thirty consecutive patients were treated with this technique on one side, and the standard multipuncture technique on the contralateral side. Each patient, being their own control, received 10-12 Botox units to each side. The orbicularis oculi muscle was injected using two different types of needles: a standard 30 g 13 mm needle for the multipunctured side and a 30 g 25 mm needle for the single puncture side. Follow up assessments were made on days 7, 15 and 120. Good results were achieved in all patients. No relevant cosmetic difference was noticeable between the two sides. The pharmacological effect lasted about 5 months, with no difference between the two techniques. Both techniques were safe and caused the same amount of bruising. The single injection was preferred by patients. The single-injection technique, on the other hand, requires more skill and experience by the operator. The single-injection technique for periocular lines is a useful alternative to the standard multipuncture technique. It reduces patients' discomfort.

Botulinum toxin A treatment of perioral rhytides.

Botulinum toxin A is well documented as a useful therapy for smoothing dynamic facial rhytides of the upper face. Most controlled studies have focused on the treatment of glabellar frown lines, horizontal forehead lines, and crow's feet. Reports of botulinum toxin A use in the lower face are few and anecdotal. We present our experience using botulinum toxin A in the lip as a treatment of vertical perioral rhytides, which resulted in the added cosmetic benefits of lip eversion and enhanced lip fullness. Eighteen patients were injected with botulinum toxin A into the vertical lip rhytides. The effect of treatment was evaluated at 2 to 3 weeks after procedure. Smoothening of hyperfunctional lines and upper lip fullness/eversion is observed in patients treated with perioral botulinum toxin A injections; 72% of patients continued treatment. In select patients, perioral botulinum toxin A results in amelioration of perioral rhytides and enhancement of lip fullness and lip eversion.

Botulinum Toxin A Treatment of Perioral Rhytides

BACKGROUND Botulinum toxin A is well documented as a useful therapy for smoothing dynamic facial rhytides of the upper face. Most controlled studies have focused on the treatment of glabellar frown lines, horizontal forehead lines, and crow's feet. Reports of botulinum toxin A use in the lower face are few and anecdotal. OBJECTIVE We present our experience using botulinum toxin A in the lip as a treatment of vertical perioral rhytides, which resulted in the added cosmetic benefits of lip eversion and enhanced lip fullness. METHODS Eighteen patients were injected with botulinum toxin A into the vertical lip rhytides. The effect of treatment was evaluated at 2 to 3 weeks after procedure. RESULTS Smoothening of hyperfunctional lines and upper lip fullness/eversion is observed in patients treated with perioral botulinum toxin A injections; 72% of patients continued treatment. CONCLUSIONS In select patients, perioral botulinum toxin A results in amelioration of perioral rhytides and enhancement of lip fullness and lip eversion.

Electrosurgery of Glabellar Frown Muscles

Introduction: Local infiltration of Botulinum toxin has gained popularity for cosmetic denervation of hyperfunctional facial lines, but its major drawback is that it only lasts up to several months. We propose an alternative procedure to treat glabellar frown lines that will last longer. Materials and Methods: Ten women aged 32–62 with hyperfunctional frown lines went through the electrical denervation procedure. Transcutaneous transection of corrugator and procerus muscles were performed electrosurgically. All patients were followed up to 6 months for evaluation of glabellar frown lines. Results: Six out of 10 patients still are unable to frown, and another four are noted to have a minimal ability to frown. The electrical denervation procedure appears to have longer lasting effects compared with previous studies with Botox injections. Surrounding edema and ecchymosis is one of the most notable complications, which occurred in 7 out of 10 patients. Discussion: The electrical denervation procedure is safe and when done properly has longer lasting effects with a very low complication rate.

The Use of Botulinum Toxin in Cosmetic Facial Surgery

Summary As surgeons, it is rare that one can perform a procedure with striking effects that are visible almost immediately. The use of BT A for hyperkinetic facial lines may reverse the aging appearance of the upper face by a decade or more literally overnight. The rhytids, lines, and folds of the forehead, glabellar, and lateral canthal area often have been described as dynamic wrinkles from repetitive muscle movements and the thinning of the epidermis and gravity. The use of BT A has shown that some of these wrinkles are eliminated totally by denervating these muscles. This result implies that the lines and wrinkles are not just structural but functional and caused by active muscle tone. Although BT A is an effective treatment, its use with laser resurfacing, chemical peeling, endoscopic brow and forehead lifts, and other rejuvenation procedures may improve their effect and longevity. Botulinum toxin A has been shown to be a reliable and reversible means of treating wrinkles and lines from hyperkinetic muscles of facial expression. Multiple studies2–4, 8, 9, 11, 13, 17 and the author's experience has shown Botox to be a safe, effective, and predictable treatment for hyperfunctional lines of the upper facial structures. The author has found the clinical use and patient acceptance to be excellent. No untoward side effects have been seen in the series performed by the author. The high cost of the BT A and its short storage life are relative drawbacks. Long-term follow-up past 1988 is not available for cosmetic treatment and will be helpful in determining the continuum of follow-up treatments, prolonged response, and development of immunity to BT A.

Facial rejuvenation with botulinum

The authors present a prospective clinical study representing a 15-month experience with the use of Botulinum toxin type A (Botox) for facial rejuvenation. Patient selection and evaluation, classification of animation lines, techniques, results, and complications are discussed. After listing the main factors responsible for the aging process and describing the four basic patterns of facial animation of the upper face, the authors discuss current surgical and nonsurgical methods employed by facial plastic surgeons to correct hyperfunctional animation lines. Observation of the absence of hyperfunctional facial lines in patients affected by Bell's palsy prompted the use of Botox in treating selected healthy aesthetic surgical patients. The pharmacology and contraindications for use of botulinum toxin A are presented. The authors then present the results of their series of 23 patients who were selected based on certain criteria. The study included both subjective and objective evaluations of the results comparing preoperative and postoperative upper facial hyperfunctional lines. Photo documentation was obtained from all patients. All patients received a history and physical and received pretreatment education. Each patient was evaluated for length and depth of wrinkles based on a standard evaluation form that is included in the article. Storage and preparation of Botox for injection is detailed and the injection technique described. EMG monitoring was utilized to determine the most active part of the muscle. Patients were evaluated for posttreatment results 1 week to 10 days after treatment. The results were evaluated according to the pretreatment evaluation category. The patients then gave a subjective evaluation of the results. In the discussion of their results, the authors differentiate between hyperfunctioning facial lines and wrinkles. Since the underlying cause of hyperfunctional lines is excess pull of the skin by facial muscles, the use of Botox to induce temporary muscle paralysis offers a solution to these muscle actions. Also addressed is the difficulty in determining the exact minimal dose of Botox required for the particular patient. The exact duration of the clinical effect of Botox injection is not known, however, the length of effect was approximately 6 months depending on location treated. In conclusion, the authors determined that Botox is a safe, easy to perform, and effective treatment for eliminating the hyperfunctional facial muscle action that is responsible for wrinkling.

Treatment of hyperfunctional lines of the face with botulinum toxin A.

Since Botulinum toxin A became a mainstay therapy for blepharospasm, its use in treating other dystonic conditions, spasticity disorders, as well as hyperfunctional lines of the face has increased exponentially in recent years. The following article summarizes our experience in establishing a safe and reliable method of administration of botulinum toxin A for treating hyperfunctional lines of the face.

Complications of botulinum A exotoxin for hyperfunctional lines.

Clostridium botulinum type A exotoxin is one of the recent advances for treatment of the aging face. Due to the sudden and exponential surge in popularity, there is little precise consensus regarding its safety and efficacy. Many of the reported complications associated with its aesthetic use are few and anecdotal. As we gain more experience and long-term follow-up with this procedure, complications and their treatment can be better documented. As most of the salutary effects of Botulinum toxin are temporary, fortunately, so too are the complications associated with this form of therapy.

Oculoplastic experience with the cosmetic use of botulinum A exotoxin.

Botulinum toxin is a neuromuscular blocking agent produced by the bacterium Clostridium botulinum. It has been used as a therapeutic agent in ophthalmology for over 18 years. To present the cosmetic use of botulinum toxin in oculoplastic surgery. We present our experience with botulinum toxin as a cosmetic agent. Botulinum toxin was successful in treating hyperfunctional lines of the face and neck. Botulinum toxin is a safe and effective method of treating dynamic lines of the face and neck.

The management of hyperfunctional facial lines with botulinum toxin. A collaborative study of 210 injection sites in 162 patients.

To determine the optimum dose and efficacy of botulinum toxin injections in the management of hyperfunctional facial lines. This study included 210 hyperfunctional facial sites in 162 different patients. The patients had preinjection and postinjection photographic documentation and ratings on a 4-point qualitative evaluation scale of lines at rest and with action. The patients then had botulinum toxin type A injections via a monopolar hollow bore, Teflon-coated electromyographic needle into the facial muscles associated with the hyperfunctional lines. The total dose for each region of 1.25 to 25 U was divided into 1.25- to 5-U aliquots representing 0.1 to 0.2 mL per injection site, depending on the site and the prior experience with that patient on using toxin. The patients had their reevaluation at 2 to 3 weeks after injection. Patients returned for further follow-up when the therapeutic effect diminished. One hundred sixty-two patients had 210 hyperfunctional sites evaluated and injected. The group consisted of 25 male patients and 137 female patients ranging in age from 21 to 78 years with a mean (+/-SD) of 46.1 (+/-1.98) years. All patients had cosmetically troubling hyperfunctional lines involving the forehead, glabella, crow's feet (lateral canthal lines), nasolabial area, platysma, and mentalis region. All patients had an effect of toxin within the first 24 to 72 hours. Ninety-five percent of the patients treated had cosmetic improvement of unsightly facial lines or contractions. The best results were achieved in management of the forehead lines, followed by glabella, crow's feet, and nasolabial. The dose for forehead lines was 5 to 25 U (mean +/- SD, 17.3 +/- 6.2 U); glabellar lines, 5 to 20 U (mean +/- SD, 11.1 +/- 3.1 U); crow's feet, 5 to 15 U (mean +/- SD, 6.2 +/- 1.6 U); nasolabial, 2.5 to 5 U (mean +/- SD, 3.12 +/- 1.2 U); and platysma, 10 to 20 (mean +/- SD, 15 +/- 4.0 U). Evaluation by age and site suggested a trend of increased toxin dose with increased age. Effects of the toxin are usually seen 24 to 72 hours after injection, and last from 3 to 6 months, whereon the increased muscular activity returns, as do the hyperfunctional lines. The only morbidity was related to temporary mild weakness of other adjacent facial muscles. There were no systemic side effects noted. Botulinum toxin is a safe and important adjunctive technique for the management of patients with symptomatic hyperfunctional facial lines.

Botulinum Toxin-Reply

I thank the Carruthers for their comment regarding our article Botulinum Toxin for the Treatment of Hyperfunctional Lines of the Face. 1 This article was the first of a series that our group wrote on the use of botulinum toxin for the management of facial lines. It was a report of our observations of the toxin's cosmetic effect on 26 patients who were being treated with botulinum toxin (... 24 patients had dystonic movements of the face, with hyperfunctional lines as a primary or secondary complaint). As is stated in the article, we and our patients noticed a diminution of the harshness of appearance and depth of hyperfunctional facial lines after the injection for facial spasms. The cosmetic benefits are not easily quantified, and the doses and injections were aimed at treating dystonic spasms. The purpose of this limited study was to address the possible benefit for cosmetic improvement of hyperfunctional

Botulinum Toxin for the Treatment of Hyperfunctional Lines of the Face

To determine the effectiveness of botulinum toxin injections for the management of hyperfunctional facial lines in patients with dystonia. Twenty-six patients were included in the study: 24 patients had dystonic movement of the face as either a primary or secondary component, and two patients were treated for purely hyperfunctional lines. Botulinum toxin type A was injected via a monopolar hollow-bore Teflon-coated electromyography needle into the facial muscles associated with the hyperfunctional lines. Doses were divided into 1.25- to 10-U aliquots. Qualitative assessments by the patient and physician were made before injection and 2 to 3 weeks after injection. Twenty-six patients (two male and 24 female) with hyperfunctional lines were included. The ages were from 32 to 84 years with an average age of 59 years. Twenty had dystonia, four had hemifacial spasm, and two had pure hyperfunction without neuromuscular disease. All of the patients had an effect of toxin within the first 24 to 72 hours. All of the patients experienced benefit from the toxin injections with partial or total resolution of painful contractions or unsightly hyperfunctional lines and spasms. The effects of the injection lasted 3 to 6 months. No systemic side effects were noted. Adverse effects included mild, temporary eyelid or lip weakness. Based on this initial pilot study, botulinum toxin may be an important new option for the treatment of patients with hyperfunctional facial lines.