Understanding upper face is key to successful Botox tx

Paris - Botulinum toxin type A and fillers have become a mainstay in cosmetic interventions and a very powerful tool in anti-aging procedures worldwide.

How and precisely where the skilled physician should use these tools to achieve maximum positive aesthetic results was explained by Herve Raspaldo, M.D., at the Anti-Aging Medicine World Congress here.

"Understanding the anatomy of the glabella and the upper face is key in achieving successful aesthetic results in patients. If the physician has a strong knowledge in this, he or she will have a much easier time with the topographic markings as well as crucial injection principles - including site, dosages and methods - facilitating the employment of botulinum toxin type A and producing wonderful results," says Dr. Raspaldo, a plastic surgeon from Cannes, France.

Dr. Raspaldo prefers to use Botox (Allergan) for the upper face - which relaxes the muscles, treating the cause of expression lines - and to use fillers or perform facelifts for the middle and lower parts of the face, ultimately tightening the tissues there.

Four main muscles

According to Dr. Raspaldo, the aesthetic physician must concentrate on four main muscles, namely the frontal muscle, the procerus (or pyramidal muscle), the orbicular muscle of the eyelids and the deeper corrugator muscle (or supercilii muscle), in order to effect an aesthetic, noninvasive lifting of the face.

"It is paramount to understand that the injection of the toxin spreads 1 cm around its injection site. Technique-wise, it serves no purpose and is even a little risky to massage the area injected, as you can cause the product to spread well beyond the cubic centimeter," he says.

The frontal muscle is a flat muscle starting from the eyebrows and joining the occipital muscle behind, connected to it via the fibrous galea aponeurotica. When it contracts, it raises the eyebrows and is responsible for the horizontal lines on the forehead. Here, Dr. Raspaldo likes to give 2 to 2.5 units of Botox subcutaneously, injecting at least 2 cm from the line joining the two eyebrow heads, then two injections laterally 2 cm away, then two further away and higher up, creating a "V" pattern opening upward, starting from, and moving away from, the eyebrows and the edge of the orbits. Depending on the depth of the wrinkles, Dr. Raspaldo administers two to four injections per side.

The corrugator or supercilii muscle is inserted over the bone at the nasion, where the nasal bone meets the frontal bone. It joins and inserts in the skin where the head and the body of the eyebrows meet. It is a plump muscle, bringing the heads of the eyebrows together when contracted, and is responsible for the frown line or vertical lines between the eyebrows. Here, the surgeon recommends two injections per side - the first located 1 cm from the edge of the orbit near the top of the eyebrow and the second 1 cm higher, parallel to the eyebrow arch and the edge of the orbit. Each injection point receives 4 units to 5 units, making 8 units to 10 units per corrugator muscle.

Procerus muscle

The procerus or pyramidal muscle is a flat muscle running from the glabella to the nasal root. When it contracts, it is responsible for the horizontal lines at the nasal root. Dr. Raspaldo administers 4 units subcutaneously at the root of the nose between the eyebrows and at the end of a "V" traced by the two injections of the corrugator muscles, making a total of 20 units to treat glabellar wrinkles or vertical lines between the eyebrows.