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Facial Plast Surg 2011; 27(6): 529-539
DOI: 10.1055/s-0031-1298786
© Thieme Medical Publishers

Botulinum Toxin: Clinical Techniques, Applications, and Complications

Scott Stephan1 , Tom D. Wang1
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
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Publication History

Publication Date:
28 December 2011 (online)

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ABSTRACT

This article outlines practice routines, clinical techniques, applications, and complications of botulinum toxin type A treatment of mimetic facial and neck muscles. Detailed descriptions are provided for each clinical indication that maximize the treatment of the intended muscle groups while minimizing potential complications.

KEYWORDS

Botulinum - glabellar rhytids - Botox

REFERENCES

  • 1 Wise J B, Greco T. Injectable treatments for the aging face.  Facial Plast Surg. 2006;  22 140-146
    Google Scholar
  • 2 Allergan Inc. 2005. Prescribing information for Botox Cosmetic. Online 2006 July 25. Available at: http://www.botox.com Last accessed December 15, 2011
    Google Scholar
  • 3 Scott A B. The role of botulinum toxin type A in the management of strabismus. In: Brin M F, Hallett M, Jankovic J, eds. Scientific and Therapeutic Aspects of Botulinum Toxin. Philadelphia: Lippincott Williams and Wilkins; 2002: 189-195
    Google Scholar
  • 4 Comella C L. Cervical dystonia: treatment with botulinum toxin serotype A as Botox or Dysport. In: Brin M F, Hallett M, Jankovic J, eds. Scientific and Therapeutic Aspects of Botulinum Toxin. Philadelphia: Lippincott Williams and Wilkins; 2002: 359-364
    Google Scholar
  • 5 Blitzer A, Zalvan C, Gonzalez-Yanez O, Brin M F. Botulinum toxin type A injections for the management of hyperfunctional larynx. In: Brin M F, Hallett M, Jankovic J, eds. Scientific and Therapeutic Aspects of Botulinum Toxin. Philadelphia: Lippincott Williams and Wilkins; 2002: 207-216
    Google Scholar
  • 6 Brin M F, Binder W, Blitzer A et al.. Botulinum toxin type A BOTOX for pain and headache. In: Brin M F, Hallett M, Jankovic J, eds. Scientific and Therapeutic Aspects of Botulinum Toxin. Philadelphia: Lippincott Williams and Wilkins; 2011: 233-250
    Google Scholar
  • 7 Schwartz M FB. Botulinum toxin A therapy for temporomandibular disorders. In: Brin M F, Hallett M, Jankovic J, eds. Scientific and Therapeutic Aspects of Botulinum Toxin. Philadelphia: Lippincott Williams and Wilkins; 2002: 259
    Google Scholar
  • 8 Tintner R JJ. Botulinum toxin type A in the management of oromandibular dystonia and bruxism. In: Brin M F, Hallett M, Jankovic J, eds. Scientific and Therapeutic Aspects of Botulinum Toxin. Philadelphia: Lippincott Williams and Wilkins; 2002: 343-350
    Google Scholar
  • 9 FDA requires boxed warning for all botulinum toxin products. FDA News Release 2009 April 30. Available at: http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm149574.htm Last accessed December 15, 2011
    Google Scholar
  • 10 Wohlfarth K, Sycha T, Ranoux D, Naver H, Caird D. Dose equivalence of two commercial preparations of botulinum neurotoxin type A: time for a reassessment?.  Curr Med Res Opin. 2009;  25 1573-1584
    Google Scholar
  • 11 Ranoux D, Gury C, Fondarai J, Mas J L, Zuber M. Respective potencies of Botox and Dysport: a double blind, randomised, crossover study in cervical dystonia.  J Neurol Neurosurg Psychiatry. 2002;  72 459-462
    Google Scholar
  • 12 Karsai S, Raulin C. Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology.  Dermatol Surg. 2009;  35 1-8
    Google Scholar
  • 13 Kane M, Donofrio L, Ascher B et al.. Expanding the use of neurotoxins in facial aesthetics: a consensus panel's assessment and recommendations.  J Drugs Dermatol. 2010;  9 (1, Suppl) s7-s22 quiz s23-s25
    Google Scholar
  • 14 Hexsel D, Rutowitsch M S, de Castro L C, do Prado D Z, Lima M M. Blind multicenter study of the efficacy and safety of injections of a commercial preparation of botulinum toxin type A reconstituted up to 15 days before injection.  Dermatol Surg. 2009;  35 933-939 discussion 940
    Google Scholar
  • 15 Hexsel D M, De Almeida A T, Rutowitsch M et al.. Multicenter, double-blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application.  Dermatol Surg. 2003;  29 523-529 discussion 529
    Google Scholar
  • 16 Hui J I, Lee W W. Efficacy of fresh versus refrigerated botulinum toxin in the treatment of lateral periorbital rhytids.  Ophthal Plast Reconstr Surg. 2007;  23 433-438
    Google Scholar
  • 17 Parsa A A, Lye K D, Parsa F D. Reconstituted botulinum type A neurotoxin: clinical efficacy after long-term freezing before use.  Aesthetic Plast Surg. 2007;  31 188-191 discussion 192-193
    Google Scholar
  • 18 Yang G C, Chiu R J, Gillman G S. Questioning the need to use Botox within 4 hours of reconstitution: a study of fresh vs 2-week-old Botox.  Arch Facial Plast Surg. 2008;  10 273-279
    Google Scholar
  • 19 Thomas J P, Siupsinskiene N. Frozen versus fresh reconstituted botox for laryngeal dystonia.  Otolaryngol Head Neck Surg. 2006;  135 204-208
    Google Scholar
  • 20 Sloop R R, Cole B A, Escutin R O. Reconstituted botulinum toxin type A does not lose potency in humans if it is refrozen or refrigerated for 2 weeks before use.  Neurology. 1997;  48 249-253
    Google Scholar
  • 21 Alam M, Yoo S S, Wrone D A, White L E, Kim J Y. Sterility assessment of multiple use botulinum A exotoxin vials: a prospective simulation.  J Am Acad Dermatol. 2006;  55 272-275
    Google Scholar
  • 22 BOTOX (Botulinum Toxin Type A) Purified Neurotoxin Complex: Advanced Toxin Technology [product monograph]. Allergan Inc., assignee. BOTOX (Botulinum Toxin Type A) Purified Neurotoxin Complex: Advanced Toxin Technology [product monograph]. Irvine, CA: patent Rx 9161; 1998
    Google Scholar
  • 23 Carruthers J, Fagien S, Matarasso S L. Botox Consensus Group . Consensus recommendations on the use of botulinum toxin type a in facial aesthetics.  Plast Reconstr Surg. 2004;  114 (6, Suppl) 1S-22S
    Google Scholar
  • 24 Dodick D W, Turkel C C, DeGryse R E PREEMPT Chronic Migraine Study Group et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program.  Headache. 2010;  50 921-936
    Google Scholar
  • 25 FDA approves Botox to treat chronic migraines. FDA News Release 2010 October 21. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm229782.htm Last accessed December 15, 2011
    Google Scholar
  • 26 Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and lower face and neck.  Dermatol Surg. 2003;  29 468-476
    Google Scholar
  • 27 Ascher B, Zakine B, Kestemont P, Baspeyras M, Bougara A, Santini J. A multicenter, randomized, double-blind, placebo-controlled study of efficacy and safety of 3 doses of botulinum toxin A in the treatment of glabellar lines.  J Am Acad Dermatol. 2004;  51 223-233
    Google Scholar
  • 28 Rzany B, Ascher B, Fratila A, Monheit G D, Talarico S, Sterry W. Efficacy and safety of 3- and 5-injection patterns (30 and 50 U) of botulinum toxin A (Dysport) for the treatment of wrinkles in the glabella and the central forehead region.  Arch Dermatol. 2006;  142 320-326
    Google Scholar
  • 29 Monheit G, Carruthers A, Brandt F, Rand R. A randomized, double-blind, placebo-controlled study of botulinum toxin type A for the treatment of glabellar lines: determination of optimal dose.  Dermatol Surg. 2007;  33 (1 Spec No.) S51-S59
    Google Scholar
  • 30 Kane M A, Brandt F, Rohrich R J, Narins R S, Monheit G D, Huber M B. Reloxin Investigational Group . Evaluation of variable-dose treatment with a new U.S. Botulinum Toxin Type A (Dysport) for correction of moderate to severe glabellar lines: results from a phase III, randomized, double-blind, placebo-controlled study.  Plast Reconstr Surg. 2009;  124 1619-1629
    Google Scholar
  • 31 Rzany B, ll-Muller D, Grablowitz D, Heckmann M, Caird D. Repeated botulinum toxin A injections for the treatment of lines in the upper face: a retrospective study of 4,103 treatments in 945 patients.  Dermatol Surg. 2007;  33 S18-S25
    Google Scholar
  • 32 Carruthers J A, Lowe N J, Menter M A BOTOX Glabellar Lines I Study Group et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines.  J Am Acad Dermatol. 2002;  46 840-849
    Google Scholar
  • 33 Carruthers J D, Lowe N J, Menter M A, Gibson J, Eadie N. Botox Glabellar Lines II Study Group . Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines.  Plast Reconstr Surg. 2003;  112 1089-1098
    Google Scholar
  • 34 Carruthers A, Carruthers J. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids.  Dermatol Surg. 2005;  31 1297-1303
    Google Scholar
  • 35 Sclafani A P, Jung M. Desired position, shape, and dynamic range of the normal adult eyebrow.  Arch Facial Plast Surg. 2010;  12 123-127
    Google Scholar
  • 36 Ahn M S, Catten M, Maas C S. Temporal brow lift using botulinum toxin A.  Plast Reconstr Surg. 2000;  105 1129-1135 discussion 1136-1139
    Google Scholar
  • 37 Blitzer A, Brin M F, Keen M S, Aviv J E. Botulinum toxin for the treatment of hyperfunctional lines of the face.  Arch Otolaryngol Head Neck Surg. 1993;  119 1018-1022
    Google Scholar
  • 38 Matarasso S L, Matarasso A. Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids.  Plast Reconstr Surg. 2001;  108 208-214 discussion 215-217
    Google Scholar
  • 39 Matarasso S L, Matarasso A. Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids.  Plast Reconstr Surg. 2001;  108 208-214 discussion 215-217
    Google Scholar
  • 40 Petropoulos I, Noussios G, Chouridis P, Kontzoglou G, Karagiannidis K. Crow's feet treatment with botulinum toxin type A.  The Internet Journal of Aesthetic and Antiaging Medicine. 2008;  1
    Google Scholar
  • 41 Ascher B, Rzany B J, Grover R. Efficacy and safety of botulinum toxin type A in the treatment of lateral crow's feet: double-blind, placebo-controlled, dose-ranging study.  Dermatol Surg. 2009;  35 1478-1486
    Google Scholar
  • 42 Lowe N J, Ascher B, Heckmann M, Kumar C, Fraczek S, Eadie N. Botox Facial Aesthetics Study Team . Double-blind, randomized, placebo-controlled, dose-response study of the safety and efficacy of botulinum toxin type A in subjects with crow's feet.  Dermatol Surg. 2005;  31 257-262
    Google Scholar
  • 43 de Maio M RB. Botulinum Toxin in Aesthetic Medicine. Heidelberg, Germany: Springer-Verlag; 2007
    Google Scholar
  • 44 Polo M. Botulinum toxin type A in the treatment of excessive gingival display.  Am J Orthod Dentofacial Orthop. 2005;  127 214-218 quiz 261
    Google Scholar
  • 45 Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: adjunctive use in facial aesthetic surgery.  Plast Reconstr Surg. 1999;  103 701-713
    Google Scholar
  • 46 Matarasso A, Matarasso S L, Brandt F S, Bellman B. Botulinum A exotoxin for the management of platysma bands.  Plast Reconstr Surg. 1999;  103 645-652 discussion 653-655
    Google Scholar
  • 47 Hoefflin S M. The platysma aponeurosis.  Plast Reconstr Surg. 1996;  97 1080
    Google Scholar
  • 48 Kane M A. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A.  Plast Reconstr Surg. 1999;  103 656-663 discussion 664-665
    Google Scholar
  • 49 Carruthers A, Carruthers J. Clinical indications and injection technique for the cosmetic use of botulinum A exotoxin.  Dermatol Surg. 1998;  24 1189-1194
    Google Scholar
  • 50 Clark R P, Berris C E. Botulinum toxin: a treatment for facial asymmetry caused by facial nerve paralysis.  Plast Reconstr Surg. 1989;  84 353-355
    Google Scholar
  • 51 Finn J C. Botulinum toxin type A: fine-tuning treatment of facial nerve injury.  J Drugs Dermatol. 2004;  3 133-137
    Google Scholar
  • 52 Carruthers J D, Carruthers A. Botulinum A exotoxin in clinical ophthalmology.  Can J Ophthalmol. 1996;  31 389-400
    Google Scholar
  • 53 Tsui J K. Botulinum toxin as a therapeutic agent.  Pharmacol Ther. 1996;  72 13-24
    Google Scholar
  • 54 Dysport (abobotulinumtoxinA) [package insert]. 4–29–2009. Brisbane, CA and Scottsdale AZ: Tercica, Inc. (a subsidiary of the Ipsen Group and Medicis Aesthetics Inc.) 
    Google Scholar
  • 55 Klein A W. Contraindications and complications with the use of botulinum toxin.  Clin Dermatol. 2004;  22 66-75
    Google Scholar

Tom D. WangM.D. 

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Oregon Health and Science University

3181 SW Sam Jackson Park Road, Portland, OR 97239

Email: wangt@ohsu.edu

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