Botulinum Toxin Injection for Facial Wrinkles



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Botulinum toxin injection for treatment of facial wrinkles is the most frequently performed cosmetic procedure in the United States, and it is one of the most common entry procedures for clinicians seeking to incorporate aesthetic treatments into their practice. Treatment of frown lines and crow's feet, which are the cosmetic indications approved by the U.S. Food and Drug Administration, and horizontal forehead lines, offers predictable results, has few adverse effects, and is associated with high patient satisfaction. Wrinkles are formed by dermal atrophy and repetitive contraction of underlying facial musculature. Botulinum toxin is a potent neurotoxin that inhibits release of acetylcholine at the neuromuscular junction. Injection of small quantities of botulinum toxin into specific overactive muscles causes localized muscle relaxation that smooths the overlying skin and reduces wrinkles. Botulinum toxin effects take about two weeks to fully develop and last three to four months. Dynamic wrinkles, seen during muscle contraction, yield more dramatic results than static wrinkles, which are visible at rest. Botulinum toxin injection is contraindicated in persons with keloidal scarring, neuromuscular disorders (e.g., myasthenia gravis), allergies to constituents of botulinum toxin products, and body dysmorphic disorder. Minor bruising can occur with botulinum toxin injection. Temporary blepharoptosis and eyebrow ptosis are rare complications that are technique-dependent; incidence declines as injector skill improves.

Botulinum toxin injection for treatment of facial wrinkles is the most frequently performed cosmetic procedure in the United States,1 and it is one of the most common entry procedures for clinicians seeking to incorporate aesthetic treatments into their practice.2 Botulinum toxin injection, particularly in the upper one-third of the face, offers predictable results,3 has few adverse effects,4 and is associated with high patient satisfaction.5 This article reviews relevant facial anatomy, patient selection, complications, and injection technique for cosmetic botulinum toxin treatment with a focus on frown lines. It is, however, not intended as a replacement for a formal instructional course.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Botulinum toxin serotype A is safe and effective for reduction of frown lines.

A

9, 12, 13, 20, 21

Botulinum toxin serotype A is safe and effective for reduction of crow's feet.

A

12, 21, 24, 25

In preparation for botulinum toxin treatment, patients should be advised to discontinue aspirin and any medication or dietary supplements associated with bruising for two weeks before treatment.

C

17, 23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Botulinum toxin serotype A is safe and effective for reduction of frown lines.

A

9, 12, 13, 20, 21

Botulinum toxin serotype A is safe and effective for reduction of crow's feet.

A

12, 21, 24, 25

In preparation for botulinum toxin treatment, patients should be advised to discontinue aspirin and any medication or dietary supplements associated with bruising for two weeks before treatment.

C

17, 23


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Mechanism of Action

Wrinkles are formed by dermal atrophy and repetitive contraction of underlying facial musculature. Injection of small quantities of botulinum toxin into specific overactive muscles causes localized muscle relaxation that smooths the overlying skin and reduces wrinkles.6

Botulinum toxin is a potent neurotoxin protein derived from the Clostridium botulinum bacterium. It exerts its effect at the neuromuscular junction by inhibiting the release of acetylcholine, which causes temporary chemical denervation. At the cellular level, botulinum toxin functions by cleaving a docking protein (synaptosomal-associated protein of 25 kDA [SNAP-25]) on the internal surface of neuronal membranes,

The Authors

REBECCA SMALL, MD, is an associate clinical professor in the Department of Family and Community Medicine at the University of California–San Francisco School of Medicine and the director of medical aesthetic training at Natividad Medical Center in Salinas, Calif.

Author disclosure: No relevant financial affiliations.

Address correspondence to Rebecca Small, MD, 820 Bay Ave., Ste. 246, Capitola, CA 95010 (e-mail: DrSmall@mbla.me). Reprints are not available from the author.

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