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NEUROMODULATORS AND SOFT TISSUE FILLERS Volume 15 Number 1 February 2007 Contents Preface xiii Corey S. Maas Neurotoxins Anatomic Considerations for Treatment with Botulinum Toxin 1 Gary M. Petrus, David Lewis, and Corey S. Maas Botulinum toxin A treatments continue to increase in popularity and number. Many more patients are undergoing cosmetic Botox procedures and many, diverse practitioners are providing them. The best results are obtained from a careful history and physical examination of the patient combined with a detailed understanding of facial and neck anatomy. Understanding the dynamic anatomic relationships, such as agonist–antagonist muscles and contraction force vectors, is key to providing the patient with an excellent outcome. Botulinum Toxin, Immunologic Considerations with Long-Term Repeated Use, with Emphasis on Cosmetic Applications 11 Gary Borodic Botulinum toxin is a unique pharmaceutical agent in wide-scale use for cosmetic and multiple therapeutic applications. Physicians using these agents for esthetic purposes must realize the potential for future therapeutic needs. Because most indications require repeated injections, the recipient is at risk for immunologic reactions with possible formation of neutralizing antibodies. An individual who is injected with botulinum toxin for cosmetic purposes could someday require an effective form of type A toxin for dystonia, pain, or spasticity. Diagnosis, Impact, and Management of Focal Hyperhidrosis: Treatment Review Including Botulinum Toxin Therapy 17 Joel L. Cohen, Goldie Cohen, Nowell Solish, and Christian A. Murray Idiopathic localized hyperhidrosis, called focal hyperhidrosis, affects almost 3% of the US population. The most frequent anatomic sites of involvement include the axillae, palms, soles, and face. For those affected, this condition can be extremely socially debilitating and interfere with work activities. Until recently, frequently ineffective v

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NEUROMODULATORS AND SOFT TISSUE FILLERS

Volume 15 � Number 1 � February 2007

Contents

Preface xiii

Corey S. Maas

Neurotoxins

Anatomic Considerations for Treatment with Botulinum Toxin 1

Gary M. Petrus, David Lewis, and Corey S. Maas

Botulinum toxin A treatments continue to increase in popularity and number. Manymore patients are undergoing cosmetic Botox procedures and many, diversepractitioners are providing them. The best results are obtained from a careful historyand physical examination of the patient combined with a detailed understanding offacial and neck anatomy. Understanding the dynamic anatomic relationships, such asagonist–antagonist muscles and contraction force vectors, is key to providing the patientwith an excellent outcome.

Botulinum Toxin, Immunologic Considerations with Long-Term Repeated Use,with Emphasis on Cosmetic Applications 11

Gary Borodic

Botulinum toxin is a unique pharmaceutical agent in wide-scale use for cosmetic andmultiple therapeutic applications. Physicians using these agents for esthetic purposesmust realize the potential for future therapeutic needs. Because most indications requirerepeated injections, the recipient is at risk for immunologic reactions with possibleformation of neutralizing antibodies. An individual who is injected with botulinumtoxin for cosmetic purposes could someday require an effective form of type A toxin fordystonia, pain, or spasticity.

Diagnosis, Impact, and Management of Focal Hyperhidrosis: Treatment ReviewIncluding Botulinum Toxin Therapy 17

Joel L. Cohen, Goldie Cohen, Nowell Solish, and Christian A. Murray

Idiopathic localized hyperhidrosis, called focal hyperhidrosis, affects almost 3% of theUS population. The most frequent anatomic sites of involvement include the axillae,palms, soles, and face. For those affected, this condition can be extremely sociallydebilitating and interfere with work activities. Until recently, frequently ineffective

Contentsvi

topical regimens or problematic surgical procedures have been the treatments of choice.Since 1996, intracutaneous injections of botulinum toxin have been used as a minimallyinvasive treatment for this condition with numerous studies documenting safety,efficacy, and extremely high levels of patient satisfaction. Botulinum toxin type A(Botox) was approved by the US Food and Drug Administration in 2004 for thetreatment of axillary hyperhidrosis.

Cosmetic Treatments and Strategies for the Upper Face 31

Andrew S. Frankel and Alex Markarian

Botulinum toxin type A injections have become commonplace and are an essential partof the aesthetic management of the upper face. A thorough understanding of theinterrelationships between relevant facial muscles allows clinicians to use Botox fora wide range of conditions in addition to those for which it was initially approved. Thisarticle provides an overview and strategy for using Botox to address various cosmeticissues in the upper face. The information provided serves as a practical guide forpractitioners who wish to expand their everyday use of the neurotoxin.

Botulinum Toxins for Facial Wrinkles: Beyond Glabellar Lines 41

Steven H. Dayan and Corey S. Maas

Botulinum toxin type A (BTX-A) has been used for years with excellent results for upperfacial cosmetic applications. Because of this success, the use of BTX-A for facial aestheticshas expanded to the lower facial and neck regions. BTX-A, especially when used incombination with fillers, has generally proven to be safe and efficacious in these areas.For optimal results, however, several issues must be taken into consideration, includingdosing differences versus upper facial applications, the specific type of botulinum toxinused, and the importance of precise placement and injection technique. In this article,the authors present their experience with BTX-A in the lower face and neck, and compareand contrast their current practices with those reported by others.

Complications of Botulinum Toxin Type A 51

Jean Carruthers and Alastair Carruthers

Introduced over 30 years ago for the treatment of strabismus and blepharospasm,botulinum toxin type A (BTX-A) now has established uses for various therapeutic andcosmetic purposes. Although remarkably safe and effective, BTX-A is a potent toxin.Complications can occur, particularly when used by the inexperienced injector.Thorough knowledge of its mechanism of action and effect and careful attention todosing and technique can minimize the risk of more serious adverse events.

Soft Tissue Fillers

Collagen Fillers 55

Elizabeth Rostan

This article reviews the currently available collagen injectable fillers and describesinjection techniques. Collagen was one of the first fillers for aesthetic enhancement andhas been in use for more than 20 years. In recent years there has been a surge of newinjectable fillers, with more anticipated in the near future. Despite the large number ofnew products for augmentation and wrinkle filling, there still remains a role forinjectable collagen—alone and in combination with other wrinkle fillers.

Contents vii

Hyaluronic Acid Fillers: Restylane and Perlane 63

Fredric S. Brandt and Alex Cazzaniga

The list of injectable skin fillers available for soft-tissue augmentation is constantlygrowing, giving aesthetic surgeons more options in the treatment of scars, lines, andwrinkles. Various products for soft-tissue augmentation are currently available in theUnited States based on hyaluronic acid. One should keep in mind that for thesehyaluronic acid gels to have the desired longevity they must have repeating chemicalbridges to withstand the constant mechanical and chemical enzymatic degradation towhich they are subjected once implanted. Restylane and Perlane have proved to be safe,effective, and liked by patients. The Restylane family of products is currently expandingand soon practitioners will be able to have a diversified arsenal of cross-linkedhyaluronic acid products to rejuvenate the aging face.

Hyaluronic Acid Fillers: Hylaform and Captique 77

Gary D. Monheit

Although hyaluronic acids are a relatively new treatment for facial lines and wrinkles,they have provided numerous advances in the area of cosmetic surgery. This articlediscusses the inherent properties of hyaluronic acid fillers that make them ideal fortreatment of facial lines. It encompasses a review of the current literature on US Foodand Drug Administration–approved hyaluronic acid fillers and the role that each ofthese fillers currently has in facial cosmetics. This article also discusses the potentialpitfalls and adverse effects that can be associated with using hyaluronic acids for fillingfacial lines. Finally, it serves as an overview of current techniques for clinical assessmentof patients and administration and treatment of facial lines and wrinkles.

Calcium Hydroxylapatite: Radiesse 85

Min S. Ahn

Among the array of choices for aesthetic soft tissue fillers, Radiesse occupies a uniqueniche as a safe, easily administered, ‘‘semi-permanent’’ material. Composed of calciumhydroxylapatite in a gel matrix, it has a proven safety profile and has been approved bythe US Food and Drug Administration for use in the nasolabial folds and for HIVlipoatrophy. Radiesse has evolved quickly into an effective filler for moderately deepfacial folds with high patient and physician approval.

Sculptra (Injectable Poly-L-Lactic Acid) 91

Sanjay P. Keni and Douglas M. Sidle

As contemporary antiviral therapy provides patients who have HIV effective long-termmanagement of their disease, the prevalence of facial HIV-associated lipoatrophy isincreasing. Sculptra (Dermik Laboratories, Berwyn, Pennsylvania) (injectable poly-L-lactic acid) is US Food and Drug Administration approved for the treatment of HIV-associated lipoatrophy and has been shown to increase skin thickness for up to 2 years.The number of treatment sessions depends on the volume of deficiency to be treated. Asis true for any cosmetic treatment, expectations must be carefully managed, especiallyconsidering the frequent need for multiple Sculptra treatments. The few adverse eventsresulting from poly-L-lactic acid injections consist mainly of subcutaneous noduleformation and local bruising.

Contentsviii

Autologous Fat Transfer: An In-Depth Look at Varying Concepts and Techniques 99

Kimberly J. Butterwick, Pavan K. Nootheti, Jessica W. Hsu, and Mitchel P. Goldman

Fat augmentation is safe, relatively inexpensive, and readily available. Now that cosmeticsurgeons are recognizing that facial aging is not simply due to gravity but also to atrophyof tissues, the use of fat for volume restoration is becoming even more popular. Newertechniques of Lipostructure, facial fat rebalancing, and fat autograft muscle injection(FAMI) are targeted to achieve true full-face three-dimensional rejuvenation; however,practical means of objectively measuring outcome are lacking. Basic questions remainregarding the optimal harvesting site, processing technique, and most effective injectiontechnique. Scientific research is emerging to address these issues.

Applications of Porcine Dermal Collagen (ENDURAGen) in Facial Plastic Surgery 113

Theresa A. Gurney and David W. Kim

The facial plastic and reconstructive surgeon has a variety of options for tissueaugmentation and soft tissue support. These options include autologous materials suchas fat and cartilage, solid implant materials, and injectable materials. Recently, malleablesheets of a collagen-based matrix have become available. This review focuses on thepotential applications of acellular collagen matrices and their various applications inrhinoplasty, facial slings for static reanimation, scar revision, soft tissue volumerestoration, and periorbital reconstruction.

Fillers in the Periorbital Complex 123

J. Charlie Finn and SueEllen Cox

Periorbital rejuvenation often includes volume replacement in the periorbital complex.Current blepharoplasty techniques rely on volume redistribution but often can besupplemented or replaced by volume replacement with injectable fillers. Volumereplacement can be done with several different materials, but precise placement iscritical to each. This article reviews anatomy, indications, and techniques using variousinjectable fillers in the periorbital complex. Avoidance, treatment, and identification ofcomplications are presented.

Index 133