INTRODUCTION
According to the International Society of Aesthetic Plastic Surgery (ISAPS), the number
of aesthetic surgical and nonsurgical procedures was estimated at 24.5 million in
2020. Botulinum toxin type A (BTX-A) is the leading aesthetic procedure, with over
6.2 million injections1. Formerly, the BTX-A treatment simply aimed to reduce wrinkles. Actually, appearance
harmonization and aging sign correction by preserving an increasingly natural and
lively appearance have become aesthetic goals. This specific result is usually derived
from a wider distribution of toxins for each muscular area2.
The lack of evidence evaluating many techniques described to treat facial wrinkles
with BTX-A (Table 1) results in a large variety of points and units to treat each area. Most articles
assessed outcomes with subjective and arbitrary scales that only compared results
with pictures at pre- and post-procedure3. Currently, the referred treatment is based on expert consensus and personal experience.
A larger and more detailed series of cases and prospective studies are required.
Table 1 - Literature descriptions of the treatment with BTX-A according to author and anatomic
region
| Author (year) |
Frontal Region (IS / U) |
Periorbital (IS / U) |
Glabela (IS / U) |
Nasal (IS / U) |
Total Units |
| Carruthers et al.4 (2008)
|
4-8 I.S. / 6-15 U |
4-10 I.S. / 10-30 U |
5-7 I.S. / 10-30 U |
- |
26-75 U |
| Sepehr et al.5 (2010)
|
- / 6-12,5 U |
- / 10-24 U |
- / 15-42 U |
- / 4 U |
35-82.5 U |
| Berbos & Lipham6 (2010)
|
5 ou 9 IS / 5-22,5 U |
2-3 IS / 10-30 U |
5 IS / 17,5-25 U |
- |
32.5-77.5 |
| Cartee & Monheit3 (2011)
|
6-8 IS / 12-32 U |
6 IS / 12-24 U |
5 IS / 20 U |
2 IS / 4-8 U |
48-94 U |
| Hexsel et al.7 (2011)
|
5-10 IS / 10-40 U |
6 IS / 10-30 U |
5-6 IS / 10-40 U |
2 IS / 4-8 U |
34-118 U |
| Jaspers et al.8 (2011)
|
5-7 IS / 20-28 U |
6 IS / 24 U |
5 IS / 20 UI |
- |
64-72 U |
| Ahn et al.9 (2013)
|
6-9 IS / 6-13,5 U |
6 IS / 14 U |
3 IS / 8 U |
3 IS / 6 U |
34-41.5 U |
| Gendler & Nagler10 (2015)
|
5-10 IS / U variable |
Many IS / 8-12 UI |
3-5 IS / 20 U |
2 IS / 4-8 U |
- |
| Gart et al.11 (2015)
|
6 IS/ 24-36 U |
6 IS / 18-30 U |
5 IS / 5 U |
2 IS / 6-10 U |
53-81 U |
| De Maio et al.12 (2017)
|
5-7 IS / - U |
6 IS / - U |
5 IS/ - U |
- |
- |
Table 1 - Literature descriptions of the treatment with BTX-A according to author and anatomic
region
Therefore, this study aimed to describe the author’s experience treating facial wrinkles
of women with BTX-A and suggest a standardized initial treatment method.
OBJECTIVES
This study aimed to describe the author’s experience in treating facial wrinkles of
women with BTX-A and to suggest a standardized initial treatment method.
METHODS
A scientific literature review was performed by the main author with an online search
of PubMed (NCBI, U.S. National Library of Medicine) with the Medical Subject Headings
(MeSH) “botulinum toxin and aesthetics.” The initial search resulted in 8.171 papers.
All titles and abstracts were read and screened, with 95 papers requested. These were
read fully, and 16 main papers were identified. Furthermore, a manual search was conducted
for additional references and protocols in the American Academy of Dermatology and
American Society of Plastic Surgeons and at the cross references of selected papers,
resulting in the referred papers in the “References” section. The ABC Medical School
Research Ethics Committee approved the project under number 1.813.647.
The data were collected by performing a documentary retrospective review of all medical
records from the author’s clinic in São Paulo, SP, Brazil, searching for female patients
who had been treated with BTX-A to reduce the superior third of the face rhytides
(main outcome), from March 2010 to August 2017. The treatment with BTX-A was conducted
according to Gimenez et al.13 recommendation and considering the anatomic study of the occipitofrontal muscle published
by Glattstein et al.14.
Photographic data from the clinic’s patients were retrospectively reviewed by searching
pictures at pre-and post-treatment (14 days reevaluation). Then the frontal region
static rhytides were randomly classified by the main author, as described by Carruthers
et al.15. Afterward, the data were compiled to compare frontal wrinkle grading at pre-and
post-treatment in the same patient.
To allow comparison with the literature, only the approximate average cost of BTX-A
in Brazil (Botox, US$ 200,00 – 100 U) was considered.
Statistical analyses were carried out with percentage, average (AVG), and standard
deviation (STD) using Microsoft Excel®.
The project was approved by the ABC Medical School Research Ethics Committee (number
1.813.647).
The study follows STROBE recommendations and has no sponsor or conflicts of interest.
RESULTS
The documentary review resulted in 53 female patients who underwent 156 treatments
with BTX-A, with an average age of 45.11 years.
Complete patient photographic records (pre- and post-treatment) were found in 46 of
156 treatments (Figures 1A-H e 2A-H). The patients’ frontal static rhytides were classified as previously described.
About 5% were classified as 0 and had no wrinkles at pre or post-procedure; 48% were
classified as 1 at pretreatment, and all of them had their rhytides classified as
0 at post-treatment; 33% were classified as 2 at pretreatment, and 70.58% had total
remission of wrinkles at post-treatment (classified as 0); 9% were classified as 3
before the treatment and 50% were classified as 0 at post-treatment; and 5% were classified
as 4 and were classified as 1 or 2 at post-treatment, evidencing only partial remission
of the static wrinkles.
Figure 1 - A: DMLCS, 68 years, Static Position pretreatment; B: DMLCS, 68 years, Static Position post-treatment; C: DMLCS, 68 years, Maximum brow lift pretreatment; D: DMLCS, 68 years, Maximum brow lift post-treatment; E: DMLCS, 68 years, Maximum corrugator muscles, procerus, and bunny lines contraction
pretreatment; F: DMLCS, 68 years, Maximum corrugator muscles, procerus, and bunny lines contraction
post-treatment; G: DMLCS, 68 years. Forced smile pretreatment; H: DMLCS, 68 years. Forced smile post-treatment.
Figure 1 - A: DMLCS, 68 years, Static Position pretreatment; B: DMLCS, 68 years, Static Position post-treatment; C: DMLCS, 68 years, Maximum brow lift pretreatment; D: DMLCS, 68 years, Maximum brow lift post-treatment; E: DMLCS, 68 years, Maximum corrugator muscles, procerus, and bunny lines contraction
pretreatment; F: DMLCS, 68 years, Maximum corrugator muscles, procerus, and bunny lines contraction
post-treatment; G: DMLCS, 68 years. Forced smile pretreatment; H: DMLCS, 68 years. Forced smile post-treatment.
Figure 2 - A: ALA, 32 years, Static Position pre-treatment; B: ALA, 32 years, Static Position pre-treatment; C: ALA, 32 years, Maximum brow lift pre-treatment; D: ALA, 32 years, Maximum brow lift post-treatment; E: ALA, 32 years, Maximum corrugator muscles, procerus, and bunny lines contraction
pre-treatment; F: ALA, 32 years, Maximum corrugator muscles, procerus, and bunny lines contraction
post-treatment; G: ALA, 32 years. Forced smile pre-treatment; H: ALA, 32 years. Forced smile post-treatment (A).
Figure 2 - A: ALA, 32 years, Static Position pre-treatment; B: ALA, 32 years, Static Position pre-treatment; C: ALA, 32 years, Maximum brow lift pre-treatment; D: ALA, 32 years, Maximum brow lift post-treatment; E: ALA, 32 years, Maximum corrugator muscles, procerus, and bunny lines contraction
pre-treatment; F: ALA, 32 years, Maximum corrugator muscles, procerus, and bunny lines contraction
post-treatment; G: ALA, 32 years. Forced smile pre-treatment; H: ALA, 32 years. Forced smile post-treatment (A).
The AVG total of units (U) used to treat patients was 32.43 U, with the variations
observed in Graphic 1.
Graphic 1 - Total units used to treat each patient X date of treatment
Graphic 1 - Total units used to treat each patient X date of treatment
The frontal region was treated with a range of 11–16 injection sites (I.S.) (AVG =
12.08; STD = 0.58 – Graphic 2) and between 11-26 U (AVG = 14.10 U; STD = 2.44 – Graphic 3).
Graphic 2 - Number of injection sites of BTX-A used according to region X date of treatment
Graphic 2 - Number of injection sites of BTX-A used according to region X date of treatment
Graphic 3 - Total units of BTX-A used according to region X date of treatment
Graphic 3 - Total units of BTX-A used according to region X date of treatment
The glabellar area was treated with 3 I.S. in all patients (Graphic 2), with a range of units between 3 and 12 U (AVG = 6.02; STD = 1.65; Graphic 3).
The nasal dorsum area was treated with 3 I.S. in all patients (Graphic 2), with a range of 0-16 U (AVG = 5.55; STD = 2.03; Graphic 3).
The periorbital area was treated with a variation from 2 to 10 I.S. (AVG = 4.70; STD
= 1.24; Graphic 2) and–2-16 U (AVG = 6; STD = 2.61; Graphic 3).
A schematic summary of the most common points and corresponding units found to treat
the upper and middle thirds of the face in our data is shown in Figure 3.
Approximately 82.69% of patients returned for a doctor reevaluation with an AVG time
of 13,78 days (STD = 1.42). Approximately 6.45% of patients presented lateral eyebrow
asymmetries post-procedure, corrected with 1 U reapplication at the still effective
muscle. Approximately 7.09% of patients described mild bruising after injection. No
patient had palpebral ptosis or headaches.
Booster injections were needed in the frontal midline area in 5.76% of patients, 8.33%
in the periorbital region, and 7.69% in the glabellar area.
About 49.05 patients underwent more than one procedure, ranging from 2–12 treatments
(AVG = 2.94; STD = 2.97). The average period between treatments was 262 (8.73 months;
STD = 156.85 days).
Considering the average number of units found to be 32.43 U, and the average cost
per unit of BTX-A in Brazil was US$ 2.00, the average toxin cost per treatment would
be US$ 64.86.
DISCUSSION
The average (AVG) age of patients found in our review was 45.11 years, similar to
the range in the literature: between 41.5 and 55.8 years16,17,18. The total BTX-A units to treat the superior third of the face are described as 26–118
U, as described in Table 1. The study sample oscillated at 18–54 U, with a tendency to stabilize at 28–32 U
throughout the authors’ experience (Graphic 1).
In the literature, the frontal region is widely varied (4–10 I.S. and 4–40 U) (Table 1). In our experience, the number of I.S. used to treat the referred region became
steady over the years, with 12 I.S. (Graphic 2) and 12 U (Graphic 3). The main idea is to distribute a smaller amount of toxin to treat the target muscle,
resulting in partial paralysis to elevate the eyebrow tail discretely. The study found
total or partial remission of static frontal wrinkles depending on their initial static
depth.
Treating the glabellar region with 3 points instead of 5, as described in the literature,
seems to preserve partial movement of the corrugator muscles, avoiding a “frozen look”
and preventing the possibility of palpebral ptosis (no case was found in this review).
Treating the nasal dorsum area seems to contribute to a natural result, as these muscles
directly interact with the glabellar region. Treating these muscles with intramuscular
injections of 2 units of BTX-A seems sufficient for most patients.
Treating the “crows feet” is difficult because it is formed not only by the contraction
of the orbicularis oculi muscle but also by the action of other muscles, such as the
greater zygomatic muscle, minor zygomatic muscle, and upper lip levator muscle. Therefore,
patients should be instructed that, without any muscle contraction in the face, the
“crow’s feet” folds would improve with treatment but would not disappear during a
forced a smile, for instance. In the author’s opinion, the attempt to treat with more
points or increase the BTX–Dose does not seem to make a difference in the final result;
however, more data are needed. Therefore, starting the treatment with the first point
at the lateral orbital rim with an intra-dermical injection and a second point contouring
the orbital rim, 1.5 cm apart from the first one, seem appropriate, as shown in Figure
1.
The total cost comparison considering the number of units found in the literature,
is shown in Table 2.
Table 2 - Treatment cost description according to the author (year) and cost range in US$
| Author (year) |
Units Total |
Cost range in US$ |
| Carruthers et al.4 (2008)
|
26-75 U |
US$ 52 - US$ 150
|
| Sepehr et al.5 (2010)
|
35-82.5 U |
US$ 70 – US$ 165 |
| Berbos & Lipham6 (2010)
|
32,5-77.5 U |
US$ 65 - US$ 155 |
| Cartee & Monheit3 (2011)
|
48-94 U |
US$ 96 - US$ 188 |
| Hexsel et al.7 (2011)
|
34-118 U |
US$ 68 - US$ 236 |
| Jaspers et al.8 (2011)
|
64-72 U |
US$ 128 – US$ 144 |
| Ahn et al.9 (2013)
|
34-41.5 U |
US$ 68 – US$ 83 |
| Gendler & Nagler10 (2015)
|
- |
- |
| Gart et al.11 (2015)
|
53-81 U |
US$ 106 – US$ 162 |
| AVG U described (2020) |
32.43 U |
US$ 64.86 |
Table 2 - Treatment cost description according to the author (year) and cost range in US$
The reported experience suggests that treating the superior third of the face in women
is a safe and effective procedure with a low complication rate compared to the literature.
Evidently, a prospective evaluation with standardized periods of reevaluation and
follow-up, validation in different populations, the development of objective scales
to manage wrinkles at pre and post-treatment, and the use of patient satisfaction
questionnaires should be considered.
CONCLUSIONS
The review suggests that a safe and effective technique is possible with even lower
complication rates than those found in the literature using fewer units, resulting
in lower product costs. One should always try to minimize risks in esthetic treatments.
1. Faculdade de Medicina do ABC, Cirurgia Plástica, Santo André, São Paulo, Brazil.
2. Faculdade de Medicina do ABC, Gastroenterologia, Santo André, São Paulo, Brazil.
Corresponding author: Victor Hugo Lara Cardoso de Sá Rua Tabapuã, 1341/122, Itaim Bibi, São Paulo, SP, Brazil. Zip code: 04533-014 E-mail:
vh55@uol.com.br
