Anti-Wrinkle Injections

Moderate to severe horizontal forehead wrinkles can look very obvious and make an individual seem tired and aged. This is particularly the case if they have developed deep static lines, which typically appear as multiple parallel etched lines running across the forehead. Softening these lines can significantly improve one’s appearance giving a more rested and youthful look.

Wrinkles around the eyes often appear at each lateral (outer) corner of the eye and fan outwards. These peri-canthal rhytids are variously known as “crow’s feet” and “squint lines”. The pattern can sometimes be more extensive, extending downwards to the upper cheek area and even upwards to the temples. Lines can also appear in the lower eyelid area. Similar to forehead lines, individuals with moderate to severe peri-canthal lines can look tired and aged. Hence reducing the appearance of the lines can significantly rejuvenate the eye area.

BOTOX^® is a trademarked name for a specific botulinum toxin A prescription-only medication. It acts by blocking the release of acetylcholine, a chemical messenger, from nerve endings at the junction with a muscle. The acetylcholine normally binds to receptors on the target muscle to stimulate muscle contraction. By blocking the action of these nerves on their target muscle, BOTOX^® effectively and temporarily inhibits muscle movement, which in turn can cause a temporary reduction of fine lines and wrinkles. BOTOX^® is commonly injected in the face for cosmetic purposes and is currently licensed by the US Food and Drugs Administration (FDA) for the treatment of moderate to severe forehead lines associated with frontalis muscle activity, moderate to severe lateral canthal lines (crow’s feet) and moderate to severe glabellar lines (frown lines) in adults. BOTOX^® is often used to treat several other areas on the face for cosmetic reasons; however, these are off-licence indications. It is also licensed as one form of treatment for axillary hyperhidrosis (excessive underarm sweating)

There are competing brands on the market such as Dysport^®/Azzalure^® (GALDERMA), and Bocouture^®/Xeomin^® (Merz Pharma), Myobloc^® (Solstice Neurosciences) and more recently Jeuveau^® (Evolus).  People use the term ‘Botox’ interchangeably for these various products and has become a household name, though BOTOX^® is a specific registered trademark of Allergan PLC. Research shows that these different botulinum toxin compounds may have slightly different characteristics to BOTOX^® when injected (such as the amount of diffusion or spread in the muscle, duration, and onset of action). However, in practice, these differences may not be clinically significant, despite assertions of proponents of each brand.

BOTOX^® has been used for cosmetic indications for over 25 years and in over 70 countries. As of 2018, over 7.4 million treatments (individual anatomic sites) have been performed with botulinum toxin (predominantly BOTOX^® but also Dysport^® and Xeomin^®) in the USA alone (American Society of Plastic Surgery). It is regarded as a safe treatment when injected by trained and experienced medical specialists who are licensed professionals performing the procedure in a suitable clinical environment. Despite its overall safety, it is contraindicated during pregnancy and breastfeeding as a precautionary measure (as are practically all elective cosmetic procedures), and in patients with certain co-morbidities. During the consultation, your suitability for BOTOX^® and other anti-wrinkle treatments will be carefully assessed, and you will only be offered this treatment if deemed appropriate and safe.

The risk of serious problems with BOTOX^® when injected at doses used for cosmetic purposes is rare to very rare. There are some recognised common side effects such as mild pain, swelling or bruising at the injection sites, temporary headache and flu-like symptoms for the first 24 hours, and numbness. Patients can also experience temporary blurred vision (if injected too close to the eyes). There have been isolated case reports of individuals with suspected allergies to certain botulinum toxin preparations, which may be related to the specific buffering ingredients used in those preparations.

Other risks include incorrect placement of the injection points leading to unwanted action on neighbouring muscle groups (causing, for sample, brow or lid ptosis). Inappropriate dosing can also result in over- or under-correction leading to unnatural looking results or significant asymmetry.  Excessive treatment over many years can thin the forehead muscle resulting in a permanent brow drop, increased visibility of the underlying blood vessels due to soft tissue thinning and, paradoxically, increased wrinkles.

Some patients who are over-treated may develop a form of tolerance, requiring even higher doses or more frequent treatments. Very rarely, this tolerance has been suggested to occur as a consequence of developing antibodies against the BOTOX^® protein.

Traditionally, practitioners learn to inject BOTOX^® using fixed gender-specific template patterns in a “one size fits all” approach with every patient receiving a similar injection pattern. However, there are substantial variations in facial muscle anatomy, and the location and severity of wrinkles and fine lines, between individuals. Occasionally, women may even require higher doses of BOTOX^® than men. Injecting using these templates usually results in under-or over-correction leading to unnatural facial expressions.

Systems such as Dynamic Mapping developed by Dr Rhobaye are highly individualised injecting techniques specific to each individual’s facial muscle anatomy. Injections are planned and mapped based on each patient’s specific pattern of facial expression and location of dynamic/static lines and wrinkles. Careful consideration is given to the shape and bulk of the muscle (estimated by the pattern of expression), the severity of the wrinkles, and the strength of muscle contracture. This advanced treatment methodology permits lower doses of BOTOX^® to be used more effectively, leading to more optimal results that also look natural and maintain a good degree of facial expression.

There are two main ways that cosmetic fillers can be used to treat wrinkles. By far the most commonly used and simplest method is to directly inject the wrinkles themselves using a superficial dermal filler. This technique is particularly useful for deeper imprinted or static lines that are visible at rest. However, fillers can also be used to more profoundly improve larger areas of wrinkles by modifying the action of the muscles whose contractions leads to those wrinkles. Reducing the appearance of wrinkles through indirect volume replacement (i.e. without directly filling the wrinkles themselves) is an example of a process called myomodulation, which is further discussed in Facial Harmonisation. Myomodulation describes the ability to use fillers to either inhibit or enhance muscle action depending on how and where the filler is injected.

A good example of the use of myomodulation to reduce wrinkles is in the forehead area. The forehead frontalis muscle is the primary elevator of the eyebrows during facial expression and also plays a secondary role in upper eyelid elevation. Both the forehead fat compartments and underlying bone provide a structural foundation and “expansion force’ for the frontalis muscle. This force helps to keep the frontalis muscle stretched as well as providing a mechanical advantage that assists the muscle in supporting the brows and maintain their position. In some patients with forehead volume loss, upper lid droop (ptosis) and excess skin, a compensatory increase in frontalis muscle activity (hypertonicity) is believed to occur in an attempt to prevent obstruction of the visual fields. Increased muscle activity, in turn, can result in an increase in horizontal forehead wrinkles due to the contracture of the overlying skin.

Often older patients who develop wrinkles due to compensatory frontalis hypertonicity will seek BOTOX^®️ to try and reduce the appearance of these wrinkles. However, this can result in a significant drop in the brows and upper eyelids in these patients. A preferred option is to replace lost volume underneath the muscle using a volumising hyaluronic acid filler that is injected just above the bone but under the muscle (sub-galeal plane). This treatment restores the support for the overlying soft tissue, resulting in a softening of the frontalis muscle activity (and hence wrinkles) while maintaining the brow and upper eyelid positions as far as possible. Any residual static or imprinted wrinkles visible at rest can then be treated with direct injections of a more superficial dermal filler, or smaller doses of BOTOX^®️.