Overview of Botulinum Toxin Treatment of the Upper Face
Botulinum toxin injections are commonly used to temporarily relax facial muscles to reduce the appearance of wrinkles and aid in anti-aging efforts. Wrinkles, also known as facial rhytids, can be caused by repeated muscle contractions that over time, weaken skin and cause it to fold or pleat. The toxin is injected into targeted muscles, particularly in the upper face, allowing for specific treatment of wrinkles. It can also be used to adjust eyebrow position and correct any irregularities in the face. Facial muscles typically affected include those around the eye, nose, and forehead.
Botulinum toxin works by blocking a chemical called acetylcholine, which helps our muscles to contract, hence preventing the muscles from receiving signals to contract. People generally see results in one to two days with the full effects visible within one week to one month. These effects usually last for three to four months. Ongoing repeat injections can cause the treated muscles to become weak, prolonging the duration of the effects. A review of patients who received at least three treatments showed that satisfaction improved after the fifth treatment.
This toxin is produced from the bacteria Clostridium botulinum through a process called fermentation. There are seven types of this toxin, labeled A through G. However, only types A and B are regularly used for cosmetic purposes. Each type has different variations, with four major ones being onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and RimabotulinumtoxinB.
Each variation has different properties. RimabotulinumtoxinB acts quickly but may not last as long as other types and may cover a broader area around the injection site. However, its acidic nature might make injections more uncomfortable. On the other hand, type A toxins generally take longer to show results but last longer. Among these, abobotulinumtoxinA spreads more than the others, so doctors adjust dosage accordingly. Typically, in cosmetic practices, the dose ratio is 2.5 to 1 to 1 (abobotulinumtoxinA: onabotulinumtoxinA: incobotulinumtoxinA).
Anatomy and Physiology of Botulinum Toxin Treatment of the Upper Face
The muscles that control our facial expressions are complex and unique. Unlike most muscles in our body which are attached to bones, they are often connected to the layers of the skin. This is due to a network of tissues and fibers, known as the superficial musculoaponeurotic system (or “SMAS”). This close relationship between the muscles and skin allows us to express emotions and communicate non-verbally.
Facial features, like wrinkles (also called “rhytids”), are often formed in relation to these muscles. They usually show up when a muscle contracts, and the skin lying on top of it folds or creases. Treating wrinkles, usually involves relaxing these muscles by injecting drugs into them. It’s really important to get the depth of the injection right. Inject too shallow or too deep and you could end up affecting the wrong muscle and get an unwanted result.
Botulinum toxin, also known as Botox, can also be used in the upper face not just to treat wrinkles but also to shape the position of the eyebrows. Generally, women’s eyebrows are located a few millimeters above the bony rim of the eye socket while men’s eyebrows rest on the rim. By skilfully using Botox, the eyebrows’ positions can be modified.
To better understand this, let’s talk about a few important muscles of facial expression. One of them is the orbicularis oculi (OO), which works to close the eyes and lower the eyebrows. It’s responsible for the so-called “crow’s feet” which look like lines branching out from the corners of eyes, much like wheel spokes. When the OO muscle contracts, these lines appear. If you want to lift the outer part of eyebrows or soften the crow’s feet, this muscle can be treated with Botox.
The corrugator supercilii (CS) is another muscle that helps pull the eyebrows towards the middle and downwards. You know those vertical lines between your eyebrows when you frown? They’re caused by the contraction of the CS muscle!
Meanwhile, the procerus muscle is found between the eyebrows and pulls them towards the nose. When this muscle contracts, you get horizontal lines along the bridge of your nose. Treating this muscle with Botox smoothens these lines.
Now, let’s talk about the frontalis muscle – it’s found in the forehead and lifts the eyebrows. Horizontal lines appear across your forehead when it contracts. This muscle actually works against crow’s feet and the lines between your eyebrows by lifting your brows.
Finally, there’s the depressor supercilii (DS) muscle. It pulls down the inner eyebrow. While there’s some debate whether it’s a separate muscle or part of the OO, it’s still crucial to bear in mind when treating the eyebrow area, as it can affect the position of your brows.
Why do People Need Botulinum Toxin Treatment of the Upper Face
Injections of a substance called Botulinum toxin (commonly known as Botox) are often used in cosmetic treatments to reduce facial wrinkles, fix unevenness in the face, and enhance or correct certain features that are associated with being male or female. However, these injections don’t work on all types of wrinkles, specifically those that don’t move or are very deep, which are often a result of sun damage. Apart from enhancing looks, these injections are also approved by the FDA for other medical applications. These include treating migraines, eye twitching, urinary incontinence, tightened muscles in the upper limb, an abnormal neck condition called cervical dystonia, excessive sweating in armpits, and misalignment of the eyes.
Facial asymmetry, or unevenness on both sides of the face, could be due to a facial nerve injury, a condition called facial dystonia that causes involuntary muscle contractions, or Bell’s palsy, a sudden weakness in facial muscles. In cases where one side of the face is weak (hemiparesis), Botox injections on the unaffected side can help re-balance the face. If a particular nerve branch on your face is injured, it can lead to uneven eyebrow positions or wrinkling, with one side appearing more lifted. Injecting botox to the muscle controlling the lifted brow can help reduce this imbalance. Furthermore, when a facial nerve injury causes unwanted spasms, tightness, and asymmetry on the same side of the injury due to abnormal nerve re-growth or hyperactivity, these symptoms can be managed by injecting the affected muscles with Botox.
When a Person Should Avoid Botulinum Toxin Treatment of the Upper Face
There are several reasons why a person might not be advised to have an injection of botulinum toxin. These include certain nerve and muscle diseases like amyotrophic lateral sclerosis (also known as ALS or Lou Gehrig’s disease), Lambert-Eaton syndrome, multiple sclerosis, and myasthenia gravis. Other reasons not to have the injection are if the person is allergic to any part of the botulinum toxin, if there is an active infection where the shot would be given, or if they have body dysmorphic disorder (a mental condition where a person can’t stop thinking about a flaw in their appearance that may be minor or imagined). Lastly, pregnant and breastfeeding women are also not recommended to have botulinum toxin injections because it could potentially affect the nerves and muscles.
The FDA rates botulinum toxin as a category C drug because there is a lack of patient data. This means that it’s not clear whether it’s safe to use during pregnancy. There have been instances where women who didn’t know they were pregnant received botulinum toxin injections, and there were no harmful effects on the baby. However, since botulinum toxin is not expected to get into the bloodstream after it’s given, it might not cross the placental barrier (the part of the womb that separates the mother’s blood from the baby’s blood), and this leads to a debate about whether pregnancy is a reason not to have the injection. Until we know more about its safety during pregnancy, the suggestion is not to offer botulinum toxin to pregnant or breastfeeding women.
Equipment used for Botulinum Toxin Treatment of the Upper Face
The medical procedure you’re about to undergo uses the following tools and materials:
* Botulinum toxin: This might sound a bit scary, but in reality, it’s a protein that can help certain medical conditions when used in small amounts.
* 1 mL syringes with 20-gauge needles: These are used to draw up and prepare the treatment. Alongside these, we use 30-gauge, 0.5-inch needles for the actual injection. If you prefer, insulin syringes with smaller, attached 31-gauge needles can also be used.
* 0.9% sodium chloride: This might sound like a chemistry lesson, but it’s just a scientific name for a sterile saltwater solution. We use it to dilute the botulinum toxin.
* Alcohol pads: These are used for cleaning the skin area where the injections will take place.
* Gauze: This is a soft, absorbent material used to cover the spot where the needle was inserted once the injection is done.
* Ice packs: These provide cooling relief to the areas where injections were given, if needed.
* Topical anesthetic: This is a type of medicine we can apply to the skin to numb it and make the injections a little more comfortable for you (optional).
* Marker/pencil: We sometimes use this to mark the injection sites on the skin so we know exactly where to make the injections.
Preparing for Botulinum Toxin Treatment of the Upper Face
Botulinum toxin, a substance often used in cosmetic procedures, commonly comes in a powdered form. It’s usually stored in cool conditions (2-8 degrees Celsius to be precise) to maintain its effectiveness, and can stay useful for up to 36 months. One exception is incobotulinumtoxinA, a specific type of botulinum toxin, which can be stored at room temperature for up to 3 years.
Once the time comes for use, doctors mix the toxin powder with a special type of saline. The common practice is to do this just within 24 hours of use and preferably to keep the mixture cool. However, latest recommendations from experts say that mixing the toxin with saline containing a substance called bacteriostatic can make the patient feel less discomfort during injection.
The mixture can also be safely stored in the fridge for up to 4 weeks without the risk of it getting spoilt or less effective. Another type of toxin, rimabotulinumtoxinB, doesn’t need this preparation before use.
While making the mixture, healthcare providers calculate the concentration they need accurately in units/mL before going on to mix the saline and the toxin in specific proportions. An Example of this is adding 2.5 mL of saline to 100 units of toxin to get 4 units of toxin in each 0.1 mL of the mixture.
However, doctors have to be careful when making these mixes because too much dilution can carry the risk of the toxin spreading to areas it’s not intended for. This can lead to unwanted side effects, like drooping eyelids and less effective results.
The mixture is prepared by drawing saline using a needle into a sealed container of the toxin. It should be mixed gently to avoid damaging the toxin. The mixture is then drawn back into a syringe, ready for injecting. A very thin needle is commonly used to help reduce discomfort during the procedure.
Finally, to reduce discomfort and chance of bruising, patients are advised to avoid supplements or medications capable of increasing bruising like vitamin E, aspirin, and alcohol, to mention a few. Applying an ice pack and topical anesthesia to the area that will be injected can also help ease pain and reduce bleeding. Even a vibration device can also be used to reduce the pain of injection.
How is Botulinum Toxin Treatment of the Upper Face performed
Before performing any medical procedure, it’s important that your face is clean; this includes removing any makeup. Sometimes, doctors or nurses might mark the places on your face where they’ll administer the treatment, but the actual injection will happen next to this mark to avoid leaving a permanent mark on your skin. There’s no one-size-fits-all approach to these treatments – they can be modified according to each person’s physical needs. For instance, men usually have larger and stronger facial muscles, so they might need larger doses of the treatment.
One of the most commonly treated areas is between the eyebrows, a region known as the “glabella”. Here, doctors will first find the muscles responsible for furrowing the brow. To make sure they get the right spot, they may ask you to move your eyebrows together and use their fingers to feel the muscles. It’s important to insert the injections deeply enough to avoid other muscles in the area, which could make the treatment less effective. They’ll also ask you to remain upright for a few hours after the treatment, so the medicine doesn’t move to unwanted areas, which could potentially cause a droopy eyelid. The aim is to be careful and accurate to avoid this risk, especially for patients who may have experienced this issue before.
Still in the region between the eyebrows, there’s a muscle called the “procerus”. If you don’t have any horizontal lines when you draw your eyebrows together, then you might not even need this particular part of the treatment. If it is required, the treatment is applied just beneath the skin, repeated in multiple spots. The amount used can vary widely, typically around 20-50 units, depending on the specifics of the case.
The forehead is another common treatment area, and it can be treated either directly in the muscle or just under the skin. Generally, the injection should be about 1.5 cm above the edge of the eye socket to prevent droopy eyelids. Doctors may also use their fingers to gently pull down the skin to predict how the eyebrows will look after the treatment. Typically, 10-20 units are used for women and 20-30 for men, depending on each individual case. The technique and amount used are carefully selected to achieve the desired look.
Around the eyes, the treatment should be applied just beneath the skin. Doctors will guide you to close your eyes tightly so they can feel the muscle fibers. The exact amount and areas of injection can vary, but generally, 4-15 units are used in 1-5 injection sites around each eye.
An eyebrow lift using this treatment can focus on lifting the eyebrows either more towards the middle or the sides of your face. If the aim is to lift the sides of your eyebrows, about 8-10 units may be injected directly below the eyebrow. If lifting towards the middle is the goal, different sites would be used. In any case, injections are done very carefully to avoid reaching muscles where the substance shouldn’t go.
Possible Complications of Botulinum Toxin Treatment of the Upper Face
There might be side effects from getting botulinum toxin injections, with mild bruising being the most common one. This could affect between 11% to 25% of patients. Other side effects may include drooping of the eyebrow or eyelid, numbness, dry skin, allergic reactions to the components of the injections, pain at the injection site, headaches, asymmetrical results, and results that the patient is not happy with. But, a study showed that in over 90% of cases, patients didn’t experience any side effects at all.
To reduce the chances of bruising, doctors take several precautions. They carefully avoid superficial blood vessels that can be seen more easily after removing makeup and under good lighting. After the injection, they apply pressure and ice. By gently stretching the skin, they can see superficial blood vessels. If a blood vessel is accidentally punctured, they immediately put pressure on the area. Keeping the patient slightly inclined and limiting unnecessary movement during the injection can also help. A small needle could also potentially cause less bruising. After the injection, patients should avoid bending over, exercising vigorously, or lying face down to prevent the spread of toxin and bruising. It’s recommended that patients try to keep upright for up to 3 hours after the injection.
When giving the injections, if they go too superficially or too deep in certain areas, it can lead to a drooping brow or eyelid. If this does happen, it can be treated with apraclonidine eye drops which helps the eyelid lift up by stimulating the muscle in the eyelid. The drooping could also happen if the injection is given too deeply into specific muscles. This can be avoided by being careful with where and how deep the injection goes.
Side effects from botulinum toxin can also include eyebrows dropping due to various reasons like injecting at the wrong place, neglecting to inject the opposing muscles, or injecting too much. Ipsilateral elevation (likewise referred to as “Spock deformity”) may occur if injections are only done between the mid-pupillary lines (the lines that cross through the center of your pupils when looking straight ahead).
If the injection accidentally hits the muscles that help with smiling, it can result in an uneven smile. Unwanted outcomes may also include a “shelf” at the lid/cheek junction, the appearance of a shelf when the cheeks rise during smiling without any movement of the skin around the eye. Excessive injections near the eyelids may cause various eye problems, along with temporary swelling in the area around the eye due to disrupted local lymphatic drainage (the body’s ‘waste disposal’ system).
Finally, uneven results might happen if the injections are not given equally on both sides of the face. Careful attention to how much is injected and consistent mixing technique can help avoid this.
What Else Should I Know About Botulinum Toxin Treatment of the Upper Face?
More people in the U.S. are getting cosmetic procedures to address signs of aging in the face, with a substantial increase from 1997 to 2010. The most common cosmetic treatment is Botulinum toxin injections, commonly known as botox. In 2019, nearly 2 million botox procedures were performed by plastic surgeons in the U.S. alone. This is more than double the number of the next most popular procedure, which is injecting hyaluronic acid into the skin to smooth wrinkles.
Recent data from follow-ups after botox injections have shown something interesting. These injections in the area between the eyebrows (known as the glabellar area) can help reduce symptoms of depression in patients. This effect was seen across different types of patients, including those getting botox injections for migraines, blinking disorders, excessive sweating, neck pain, or simply for cosmetic enhancement. Experts believe that this might be because botox eases muscle tension, which can affect mood. Since muscle tension is also a symptom of depression, its relief might be contributing to the anti-depressive effect. This is similar to how relieving muscle tension is part of the treatment for depression.
However, the same data also showed that some patients might feel an increase in depression after injections into the muscle around the eye that helps with smiling. A possible reason for this might be that botox injections make it hard for the patients to do a genuine, joyful smile, which can lead to them feeling less positive.
Considering this, doctors have to be careful in managing patient expectations. They have to weigh the patient’s distress from their specific cosmetic concerns against the risk of possible side effects from the treatment.
