KeywordsBotulinumtoxin type ANeurotoxinNeuromodulatorBotoxPharmacologyDysportXeominBotox cosmeticMuscle memoryNeurotoxin effectsBoNT/AIndicationsFacial linesUpper faceJuveau
12.1 Patient Selection and Education
Patient selection and education are important aspects in successful aesthetic BoNT/A treatment outcomes. Therefore, it is paramount that the patients understand that lines caused from muscle movement are the indications for BoNT/A treatment and it will not improve the appearance of photoaged skin or issues related to volume depletion. Photoaging and volume depletion treatment options are discussed elsewhere in this text (see Chaps. 3 and 19).
Explanation of the treatment onset, duration, and effect is crucial for the patient to understand the limitations of treatment. Male patients typically require a higher dose of BoNT/A than female patients and patients of Asian descent may require lower doses (Ahn et al. 2013; Carruthers and Carruthers 2005a). Completing a thorough consultation and history will provide the opportunity for the practitioner to gather appropriate information, provide the patient with necessary material, and allow the patient to ask questions. It is crucial the patient has realistic expectations to alleviate potential disappointment. Honest and straightforward approaches work best and are appreciated by most patients; clear documentation of aspects that were discussed should be listed in the patient record.
However, if during the consultation it is realized the patient has unrealistic expectations or s/he does not understand the effects of BoNT/A treatment, the patient will likely be dissatisfied. The consultation provides an opportunity for the practitioner to educate the patient further or to perhaps discourage treatment altogether.
Because there are several factors involved in facial aging including effects of sun exposure, loss of volume, and bone resorption, many patients may require multiple modalities in addition to BoNT/A to attain an improved appearance and excellent outcome (Carruthers and Carruthers 2005b; Carruthers et al. 1996). The practitioner should not hesitate to perform a complete assessment and offer all this information to their patient. As of publication, there are no available studies on prabotulinumtoxinA, however the dosing is the same as onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin).
Photographs provide an additional component of comprehensive documentation and should be taken of every patient before treatment and retained in the patient record (Carruthers and Carruthers 2003, 2005b; Kordestani et al. 2016). Photographic documentation will ensure effects from the BoNT/A treatment are accurately recorded and will also demonstrate pre-existing issues that are unrelated to the treatment itself or the outcome effects of BoNT/A. For example, if a patient complains of hooded, heavy lids after treatment, the pre-treatment photographs would document the lid position before the effects of the BoNT/A treatment and therefore, either support the patient’s complaint or indemnify the practitioner. Photographs provide documented evidence of appearance prior to treatment.
In addition to photographs, consider that patients tend to heighten scrutiny of their skin and face after procedures, regardless of type of treatment provided. Patients often closely analyze their skin and face after initial aesthetic treatment, whether it is a neuromodulator, dermal filler, or laser procedure. On occasion, the treatment-naïve patient might notice something on their face for the first time such as a pre-existing skin lesion (e.g., nevus) or scar, a fold or wrinkle, or a myriad of other unrelated conditions. This is another example of benefit for utilizing pre-treatment photographs because they document the characteristics of the patient’s face prior to treatment.
In addition, the patient may believe a new symptom or condition is related to the treatment and time passed may serve as an indicator of the patient’s perspective. The length of time passed since treatment can help determine the probable relationship between the BoNT/A and the onset of a new symptom. Distance in time of new complaint onset since treatment is an important variable for consideration of the complaint. For example, the author had a treatment-naïve patient who was anxious about receiving BoNT/A treatment and brought her adult daughter into the treatment room for support. The side effects, risks, and benefits of the treatment were reviewed extensively with the patient and daughter and they were given time to ask all of their questions. She consented to the treatment and it went very well. The patient was relieved that the actual injection process was expedient and she experienced no pain during treatment. However, when she was leaving the office, she felt that her forehead was numb. After a neuro assessment, the effects of BoNT/A were reviewed with the patient, including the fact that BoNT/A does not affect sensory nerves at the treatment site, and she felt better. At her 2 week follow-up, she was very pleased with the outcome of her treatment and has been a consistent BoNT/A patient since.
An additional example of a condition unrelated to BoNT/A treatment from the author’s practice is a situation in which a patient called and complained of sudden, recent onset of left sided facial paralysis although she had her BoNT/A treatment 4 months prior. It was recommended she visit her primary care provider (PCP) for evaluation for Bell’s palsy. She was examined by her PCP and was diagnosed with Bell’s palsy likely from the herpes virus, consistent with McCormick’s report (McCormick 1972). The prudent practitioner realizes BoNT/A injections are not recommended for placement in the zygomatic area because it would cause facial paralysis and an undesirable aesthetic outcome. Differentiating between and among BoNT/A effects and coincidental or unrelated situations is critical in aesthetic practice. Timely follow-up is recommended for all new patients to ensure satisfaction and answer any questions (Carruthers and Carruthers 2005b).
Lastly, a patient who has an unexpected or unflattering result should be seen by the practitioner as soon as possible, especially since an easy correction can often be achieved. Patients who present at follow-up with asymmetrical or quizzical brows, or excessive movement in an area, can easily be treated and the problem resolved with a touch-up (Carruthers and Carruthers 2005b).
12.3 Select Types of Facial Lines
There are four main types of superficial facial lines or wrinkles; (1) dynamic lines, (2) static lines, (3) crush lines, and (4) photodamage lines. The lines relevant to this chapter are dynamic lines, static lines, and crush lines. Lines caused by photodamage and other forms of ultraviolet radiation are most appropriately treated with laser treatments, chemical peels, and/or topical preparations.
Dynamic lines are formed from the dynamic motion of facial muscle contraction or expression (Carruthers and Carruthers 2005b). This muscle contraction causes lines to form in the superficial and occasionally deeper dermis layers of skin that run perpendicular to the muscle fibers. For example, the fibers of the frontalis run vertically, and the lines formed from contraction run horizontally. These types of lines respond best to neurotoxin treatment since the relaxation of the underlying muscle prevents repetitive dynamic muscle movement that lead to lines (Carruthers et al. 1996; Said et al. 2003).
Static lines are lines that are visible on the skin when there is no muscle contraction or expression—they appear to be drawn on the face (Baumann et al. 2016). This type of line can make the person look older than their true age and patients should be counseled that consistent BoNT/A treatments will smooth the lines, make the skin look more youthful, and improve appearance (Baumann et al. 2016).
Demonstration of how physical pressure affects the line is beneficial for the patient to see because often the patient will unknowingly ask for crush lines to be improved with neurotoxin. Depending on the severity and cause, crush lines may be diminished with consistent tretinoin use, laser resurfacing, dermal fillers or smoothers, sleeping in a different position, changing habits, or a combination of these (Carruthers and Carruthers 2013, 2006, 2004).
Additionally, a common misperception by patients is that the effects of the neurotoxin will remain for up to 6 months as described by the package insert or advertisement and especially if, during their consultation with the practitioner, 6 months is mentioned (Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). It is uncommon that a patient will have enduring effect for 6 months, although it is not unheard of (Baumann et al. 2016). Most patients report good effects for about 3–4 months and it is important to educate the patient appropriately to avoid disappointment.
It is also important to remember that patients will have consistent effects for many years with appropriate treatment. However, since the natural aging process will continue to affect underlying tissues and structures, periodic review of expectations and possible addition of supportive treatments may be warranted to maintain the best appearance of the patient (Hellman 1927).
In summary, information regarding the varying line types and potential treatments of must be shared with the patient, to assure patient management of their own expectations regarding possibilities and outcomes with aesthetic treatment. Patient expectations are a significant part of the entire aesthetic experience and managing expectations is crucial for both the patient’s level of satisfaction and the success of the practice.
12.4 Muscle Memory
There is an occasional additional benefit of regular neurotoxin treatment that is commonly referred to as muscle memory. Muscle memory is the memory built by repeated practice and use of any muscle. In relationship to aesthetics, muscle memory can also be engaged. Muscle memory specific to neurotoxin injection occurs when a muscle or muscle group is repeatedly treated during appropriate intervals. The treated muscles eventually lose full contractility due to possible atrophy of the muscle with results of treatment remaining longer than a period of 3–4 months (Carruthers and Carruthers 2006; Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). A common area of this phenomenon is the procerus and corrugator group. Affected patients experience decreased muscle contraction and smooth skin although the BoNT/A is no longer in effect. Consequently, the patient may ask for partial treatment or ask to stagger treatment areas that have full muscle contractility after 3 or 4 months. For example, if the patient has diminished BoNT/A effect in the orbicularis oculi areas but still enjoys good BoNT/A effect in the glabella, they may request treatment only in the orbicularis area at their appointment. A potential issue with alternating treatment sites is the lines formed from the strong and frequent contraction of the procerus and corrugator group will return, and the patient will notice less efficacy over time (Baumann et al. 2016). A more favorable approach might be treating the muscle group that is exhibiting muscle memory with a slightly lower dose during the appointment to ensure the smooth skin and lifted brows remain a constant outcome.