Chung O T in Facial Aesthetic Surgery_9781496349231

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Operative Techniques in Plastic Surgery: Facial Aesthetic

PEARLS AND PITFALLS Avoidance of denervation and ptosis of eyelid and brow

■■ To avoid diffusion of toxin into eyelid elevator muscles and ptosis, injection should be directed superiorly and obliquely. ■■ If injection is performed too far superiorly above the region of the corrugator, the medial inferior frontalis muscle can be affected causing medial brow ptosis. ■■ A total of 20–25 units of Botox (or equivalent) is typically used for treatment of the glabellar muscles. ■■ A higher dosage may be necessary in males for optimal results.

Dosing

POSTOPERATIVE CARE

■■ If upper eyelid ptosis occurs, treatments exist to elevate the ptotic upper eyelid. These treatments are designed to strengthen the eyelid retractors or to slightly weaken the upper lid protractors. Either of these treatments changes the protractor/retractor muscle balance, thereby elevating the ptotic eyelid. ■■ Initial treatment in patients with toxin-induced ptosis is to instill topical sympathomimetic eye drops. Topical drops, such as apraclonidine, stimulate the sympathetic nervous system causing contraction of Müller muscle, resulting in 1 to 3 mm of upper eyelid elevation. The drops are placed every 6 to 8 hours as needed to alleviate the ptosis. ■■ The other means to treat inadvertent upper eyelid ptosis is to inject small amounts of additional botulinum toxin into the pretarsal fibers of the orbicularis oculi muscles. Diminishing the tone and contraction of the upper eyelid protractor (orbicularis oculi muscle) also can result in upper eyelid elevation and treatment of the ptotic eyelid. ACKNOWLEDGMENT The authors thank Sebastian Cotofana, MD, PhD, for his con- tribution to the preparation of this chapter. REFERENCES 1. Monheit G. Neurotoxins: current concepts in cosmetic use on the face and neck—upper face (glabella, forehead, and crow’s feet). Plast Reconstr Surg . 2015;136(5 Suppl):72S-75S. 2. Prager W, Bee EK, Havermann I, Zschocke I. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of gla- bellar frown lines: a single-arm, prospective clinical study. Clin Interv Aging . 2013;8:449-456. 3. Jia Z, Lu H, Yang X, et al. Adverse events of botulinum toxin type A in facial rejuvenation: a systematic review and meta-analysis. Aesthetic Plast Surg . 2016;40(5):769-777.

■■ Ice packs should be provided to the patient and placed immediately after injection. ■■ Some patients may bruise post procedure, especially if anti- coagulated. This can be expected to resolve in several days. ■■ Avoidance of topical massage for 24 hours postinjection is suggested. Although some injectors suggest exercising injected facial muscles for 24 hours after a botulinum toxin injection, there is no evidence to prove that this affects outcomes. ■■ Onset of effect usually become apparent in 1 week. ■■ The neuromodulation is commonly effective for 12 to 20 weeks wherein it would need to be redosed for continued effect. This can vary from patient to patient. ■■ The outcome of botulinum toxin injection into the glabellar musculature is to decrease or alleviate the glabellar frown lines and elevate the medial brow. The cumulative effect is to eliminate the frowning or scowling appearance. 2 ■■ Satisfaction after injection of glabellar botulinum toxin is usually high. The procedure is simple, is fast, and causes no to very minimal downtime. ■■ If all of the musculature is not denervated after an injection and the patient requests additional toxin, it is simple to add toxin during a follow-up office visit.

OUTCOMES

COMPLICATIONS

■■ Inadvertent spread of the toxin into the upper eyelid retrac- tor muscles can cause ptosis of the upper eyelid via dimin- ished contraction of the levator aponeurosis/Müller muscle complex, allowing the eyelid protractors (orbicularis oculi muscles) to dominate the eyelid position. 3

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