LAS VEGAS – A technique that involves injecting tiny, closely spaced amounts of botulinum toxin A to balance the action of muscles around the eyebrows has produced natural-looking results without forehead paralysis, according to data from a 5-year study.
“Physicians mistakenly adopted maximal forehead paralysis as the desired treatment endpoint,” Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Plastic Surgery. “Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and frowned upon by the media.”
Over the years, onabotulinum toxin A treatments have evolved to create maximum frontal brow lifts while minimizing the risk of drooping. As a result, “the forehead is smooth, but the central forehead is also drooping,” said Dr. Steinsapir of the University of California, Los Angeles’ department of ophthalmology. “There may be intake lines on the side of the forehead, which can cause an unwanted treatment effect.”
In 2006, Dr. Steinsapir first described the botulinum toxin microdroplet forehead lift, a technique he developed to treat oppressive brows that leave the brow lift untreated. “I hypothesized that very small amounts of toxic botulism can be injected and effectively trapped between the skin and the underlying eye muscle on the forehead, as well as in the goose leg area,” said Dr Steinsapir, who also runs a private cosmetic practice. surgical practice in Beverly Hills, California. “This weakens the brow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is maintained and unwanted diffusion responsible for drooping eyelids is prevented.”
Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive botulism toxin microdroplet forehead lift treatments on 175 women and 53 men with an average age of 45 years. A typical treatment includes 10 mcL of injectable saline containing 0.33 U botulinum toxin A using the Botox or Xeomin product formulation. About 100 microinjections are required to complete the pattern, and all patients in the study received a total of 33 units of Botox.
Dr. Steinsapir reported that there were no cases of drooping of the upper eyelids or eyebrows caused by the treatment or cases of diplopia, “proving that this treatment can be performed safely.” Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on upper lid reflex distance, tarsal platform appearance, and brow center corneal position. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the forehead and forehead before and after treatment.
There was no significant change in reflex margin distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. “There was a slight trend for minimal brow lift, and the appearance of the tarsal platform was essentially unchanged after treatment,” he said. “It is my clinical impression that the main effect of the treatment is the softening of the eyebrow pinch which usually tightens the eyebrow and brings an unintended negative effect on the face.”
Dr. Steinsapir acknowledged that the process requires a learning curve “and a need to educate patients about the outcome of the treatment. This is more intensive than standard treatment methods.” Dr. Steinsapir has developed a detailed video tutorial that is available online at his Websiteand said he works in a treatment atlas.
The botulinum toxin microdroplet forehead lift “presents the first alternative to standard periocular treatments that cause undue forehead paralysis, brow furrowing or muscle activation,” said Dr. Steinsapir. “By controlling the depth, volume and dose of the agent, very controlled brow shaping and lifting can be done to create aesthetic enhancement with natural results, including preservation of forehead movement,” he noted.
Dr. Steinsapir received a United States patent for the microdroplet method. He said he hopes to license the technique to a pharmaceutical company to develop an FDA-approved indication so the treatment can be marketed directly to consumers. He had no other relevant financial conflicts to disclose.
d.brunk@elsevier.com
