Methods of correction of involutional changes in skin, hyper fine lines and static wrinkles as well as excess skin and changes its texture is widely used around the world, with many clinical questions still have not found a final decision. Quite often wrinkles are formed at a young age and are a consequence of emotional stress and genetic predisposition. The nature of these phenomena is predetermined in the prepubertal period and fixed unconsciously into adulthood.
Quite often wrinkles are formed at a young age and are a consequence of emotional stress and genetic predisposition. The nature of these phenomena is predetermined in the prepubertal period and fixed unconsciously into adulthood.
Hyper mimic wrinkles, most pronounced in the forehead, brow, and paraorbital region, are very common cosmetic defects. Increased activity of facial muscles is one of the precipitating factors in the development of facial wrinkles, which accelerate the involution process. Static wrinkles are formed under the influence of degenerative changes in the skin-muscular apparatus of the facial area associated with age-related changes in tissues, which are enhanced by external factors (sun exposure, gravity, bad habits, etc).
ПUsed in practice methods of correction of involutional changes in facial skin, including different types of facial massage, electrotherapy, chemical peelings, injections of intact implants, various types of dermabrasion, etc., do not allow fundamentally solve the problem, because there is no impact on the mimic muscles.
Using a surgical technique for tightening the forehead skin to remove the horizontal frontal, fronto-nasal and vertical creases in glabella, and blepharoplasty are also not always lead to desired results. In addition, these transactions involve a risk of damage to the branches of the facial nerve, the occurrence of postoperative subcutaneous hematoma, edema of the soft tissues of the face, scarring, and do not affect the main causes of mimic wrinkles.
The discovery by Allaster and Jean Carruthers (Vancouver, Canada, 1991.), the effect of botulinum toxin type A for facial wrinkles, has been significant progress in aesthetic medicine.
According to English, Professor J. Lowe – botulinum toxin opened the era of non-surgical management of facial muscles.
The basis of the botulinum toxin type A is the principle of inhibiting the exocytosis of the neurotransmitter acetylcholine in the neuromuscular junction and in autonomic cholinergic ganglia.
At the stage of the biochemical process is provided binding with specific receptors of botulinum toxin, located on the presynaptic neuron NMJ. After its accession to the peripheral presynaptic cholinergic receptor occurs internalization of associated toxin molecules into the cytosol by an energy-dependent endocytosis. Zn-dependent protease cytosol selectively splitting SNAP-25 leads to a blockade of the release of acetylcholine from presynaptic terminals of cholinergic neurons. In the future, the toxin causes irreversible blockade of transport synaptosomal protein SNAP-25. Paralysis and decrease in the amplitude of the action potential of motor end-plate muscle occurs within a few hours. However, the final process of introducing the toxin into the presynaptic ending and the blockade of presynaptic membrane takes 1 to 3-days, so the clinical effect begins to appear not immediately but after a few days after the injection.
In response to the effects of botulism toxin includes the protective mechanism of the growth of peripheral axons, which subsequently forming new nerve-muscle synapses, thereby preventing the development of muscle atrophy (including on a microscopic level), even after multiple repeated injections. The formation of new synapses takes 3 months to a year and corresponds to the terms of the drug.
It is currently used botulinum toxin type A, obtained by thin clearing and subsequent freeze-drying of bacterial culture, as a commercial product: “Botox” (firm Allergan (U.S.).
“Botox” is a lyophilized powder for injection containing 100 IU gemmagluten botulinum toxin type A complex, 0.5 mg of human plasma albumin and 0.5 mg sodium chloride. Available in a specially packaged flasks that do not require special storage conditions and transportation. For long term storage Botox requires freezing at temperatures below – 50C or +2 – +8°С. At observance of these conditions the period of the drug storage is 2 years.
Drug applied by injection directly into the target muscle.
FORMULA OF METHOD
In clinical practice, the most common drug “Botox” injected into the target muscles in the projection m.frontalis, m.corrugator supercilii, m.orbicularis oculi, m.procerus, m.nasalis, m.depressor anguli oris, platisma, m.mentalis.
The distinctive feature of the proposed method is the use of reduced dosages of the drug (up to 50 units per procedure), depending on gender, patient’s age and the number of treatment courses. The proposed approach can significantly reduce the frequency and severity of side effects and complications, as well as to minimize the risk of antibody formation.
Positive results of the proposed method were confirmed by the profilografical, empidansmetrical (Sebo and korneometria) and electromyographic studies.
INDICATIONS AND CONTRAINDICATIONS FOR USE OF METHOD
Indications: The presence of facial wrinkles in the forehead, brow, and paraorbital areas, nasal bridge, chin, horizontal and vertical lines neck and the angles of the mouth and decollete.
neuromuscular disorders (myasthenia gravis, Eaton Lambert Syndrome, etc.)
local inflammatory process
hypersensitivity to the drug
neurological diseases in history
taking medication of anticoagulants (aspirin, etc.)
somatic disorders in the acute stage
the use of drugs that enhance the action of botulinum toxin: antibiotics, aminoglycosides, curariform myo-relaxants, erythromycin, tetracycline, lincomycin, polymyxin B
not recommended for a one-time introduction of gels, silicone, collagen implants and other contour with the drug Botox into same anatomical zones)
It is known that botulinum toxin is immunogenic protein capable of inducing the synthesis of strong neutralizing antibodies, which in some cases a negative impact on patient outcomes, especially neurological. Factors that increase the risk of antibody formation, are the high doses (more than one procedure for the 100ED). It is proved that the introduction of botulism toxin type A in a dose of 50 units per procedure, antibodies hardly detected.
Injections of the drug for aesthetic indications are carried out only medical staff (dermatologists, dermatology, plastic surgeons) who have undergone special training, with experience and appropriate resolution. Institution, which conducts injections botulinum toxin should have a mandatory license to medical activity.
The room in which the procedure is carried out, must comply with sanitary and hygienic requirements of the treatment rooms.
Classification of age-related changes in facial soft tissues in the classes.
Based on proposed by us classification of age-related changes of facial tissue in classes we offer the optimal combination of algorithmic model of modern techniques to obtain expression of the aesthetic effect and saving it for long term.
Algorithm correction of age changes of facial tissue using botulinum toxin A type.
Application of combined correction methods requiring special sequence:
injectable implants injected in 3-4 weeks after dermabrasion and plastic surgeries
medicines of botulinum toxin injected 10-14 days before laser dermabrasion and 3-4 weeks after plastic surgeries
Do not combine the introduction of injectable implants and preparations of botulinum toxin simultaneously in the same area
Smoothing brow wrinkles
In the formation of brow wrinkles involved m.corugator supercilii and m.procerus. The only function of these muscles is the sliding eyebrows to express emotions. Most of them negative – anger and anxiety. Many people “knit brows”, trying to focus.
Smoothing horizontal wrinkles on the forehead
Early appearance of transverse wrinkles related to the anatomical features of the frontal muscle, which is part of the m. epicranium. Upper fibers of it vertically pass to aponeurosis of the tendon helmet. From the fascia covering the frontal muscle, depart numerous of connecting beams, woven into the skin. To smooth the frontal wrinkles patient is asked to raise the eyebrows and on the maximum amplitude mark points with pronounced facial activity. During the procedure should take into account the patient’s age and class of wrinkles, because at expressed involutional changes and large skin excess on the forehead, the brow ptosis risk is greatly increased.
Smoothing of wrinkles in periorbital area (area around eyes)
Wrinkles, diverging radially around the eyes, so called “crow’s feet”, resulting from rapid circular eye muscles.
To reduce the number of wrinkles in the “crow’s feet”area make few injections (usually 2-4 on each side) into projection area of m.orbicularis oculi on distance not less than 1 sm from the outer eye corner, as well as in the lateral part of lower eyelid in areas of maximal muscle activity. Into the area of “crow’s feet” the drug shouldn’t be injected too low, because there is possibility the break of symmetry of mouth corners and nasolabial fold owing to drug diffusion into the area ofm.zygomaticus major.
Smoothing of wrinkles on the nasal bridge
In the presence of pronounced wrinkles on the nasal bridge drug is injected directly into the m. nasalis on each side.
Smoothing wrinkles in the lower face and neck
in the lower face and neck may use botulinum toxin in areas of nose wings.
The drug injected directly into the part of m.nasalis on each side (possible complications: impaired articulation, asymmetry of the mouth corners, numbness of the upper lip).
The upper lip
Injections are performed along the red border of the upper lip intradermally directly into wrinkles, some distance from the edge of a 2 mm. The number of points of introduction – from 4 to 6 (possible complications: impaired articulation, numbness of the upper lip).
Corners of the mouth
The drug is injected subcutaneously, on each side, in m.depressor anguli oris (possible complications: impaired articulation, asymmetry of corners of the mouth, numbness of the lower lip).
The drug is injected subcutaneously, directly m.mentalis (possible complications: numbness of the lower lip).
To eliminate vertical folds, resulting from the tension leg m. platismus, the drug injected subcutaneously. The number of points from 4 to 8, to correct the horizontal wrinkles drug injected intradermally directly over the wrinkle with an interval of 1.5 – 2 cm (possible complications, dysphagia).
Intradermal injection of the drug is carried out along the horizontal wrinkles.
EFFECTIVENESS OF USE THE METHOD
We have used the drug of botulism toxin type A (in the dosage form “ВОТОХ”) to eliminate hyperkinetic wrinkles practiced since June 1997.
The basic principle of the drug “Botox” for the correction of facial wrinkles is to use smaller doses for optimal effect. Recommended doses according to age, patient’s gender and the injection zone. The aesthetic effect was manifested in the smoothing facial wrinkles and static varying degrees of severity.
Dependence of the duration of the effect by the number of courses
The frequency of complications of botulinum therapy did not exceed 3%. Allergic reactions were no observed. Analysis of complications presented in the Table.
Complications in the application of botulinum toxin.
Patients with complications assigned antihistamines, physiotherapeutic procedures, antibiotics, cephalosporin, cholinesterase inhibitors, vitamins of group B. All complications were temporary and were stopped completely for 1.5 – 3 months.
Side effects accounted for 9.45% of the total number of patients and did not require additional treatment, as were stopped on their own within 2 – 7 days (Table).
Side effects in the application botulinum toxin
1. No effect was observed in 2 patients, due, apparently, with the individual characteristics of the organism
2. The results of drug correction of “Botox” were confirmed profilografical research in studying the surface skin relief (profilograph-profilometer model 250, Russia).
3. Electromyographic study (neuromyography-01-MBN, Russia) have shown that in the time of denervation, the number of fully maintained motor mono neuron pool of units mimic muscles and the temporary inactivity of mimic muscles did not significantly affect the functional activity of the muscles in general.
1. Injections of botulism toxin type A are a relatively safe and highly effective method of temporarily eliminating wrinkles caused by overactive facial muscles.
2. Technique of the procedure is simple and allows procedure on outpatient basis without loss of patient disability.
3. The use of botulinum toxin type A in recommended doses provides a durable aesthetic effect with minimal complications.
4. Temporary denervation does not cause atrophy of facial muscles physical activity of muscles is fully restores in a period of 6 months to 1 year.
5. By influencing on the etiological component of the pathogenesis of facial wrinkles, botulinum toxin can be successfully applied not only as a therapeutic, preventive and cosmetic correction method.
6. The combination of injections of botulinum toxin with contouring plastic, different types of dermabrasion, aesthetic plastic surgery profile provides a marked and persistent correction of the results.