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Understanding the Functional Anatomy of the Frontalis and Glabellar Complex for Optimal Aesthetic Botulinum Toxin Type A Therapy

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Abstract

Background

Botulinum neurotoxin type A (BoNTA) is approved for the treatment of glabellar lines and also is commonly injected in an off-label fashion in the frontalis (i.e., frontalis epicranius) muscle to improve the appearance of horizontal forehead lines. This study aimed to review and discuss both the anatomy and physiology of the frontalis muscle and its relationship with antagonist muscles in the upper face and to provide a guide for the use of BoNTA to treat forehead rhytides while minimizing the occurrence of complications such as brow ptosis.

Methods

A PubMed search was conducted to identify practitioner opinion and clinical publications on the efficacy and safety of BoNTA for aesthetic treatment of the upper face.

Results

The use of BoNTA produces durable improvement in the appearance of moderate to severe horizontal forehead lines. Dose and injection technique must be adjusted and individualized based on the variable anatomy and function/mass of muscles in the forehead and upper face as well as on patient goals. Optimal aesthetic outcomes can be achieved by skillfully balancing the opposing effects of the frontalis muscle and its intricate interactions with the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi muscles.

Conclusions

The use of BoNTA to improve the aesthetic appearance of horizontal forehead lines is optimized when clinicians take into account variations in frontalis muscle function and position, anatomy of the brow, and proper injection technique when they devise individualized treatment regimens.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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References

  1. Botox Cosmetic (2010) (onabotulinumtoxinA): full prescribing information. Allergan Inc., Irvine

  2. Dysport (2010) (abobotulinumtoxinA): full prescribing information. Medicis Aesthetics Inc., Scottsdale

  3. Xeomin (2011) (incobotulinumtoxinA): full prescribing information. Merz Pharmaceuticals, LLC, Greensboro

  4. Ascher B, Talarico S, Cassuto D, Escobar S, Hexsel D, Jaen P, Monheit GD, Rzany B, Viel M (2010) International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit): Part I. Upper facial wrinkles. J Eur Acad Dermatol Venereol 24:1278–1284

    Article  PubMed  CAS  Google Scholar 

  5. Carruthers JD, Glogau RG, Blitzer A (2008) Advances in facial rejuvenation: Botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies: consensus recommendations. Plast Reconstr Surg 121(5):5S–30S quiz 31S–36S

    PubMed  CAS  Google Scholar 

  6. Kane M, Donofrio L, Ascher B, Hexsel D, Monheit G, Rzany B, Weiss R (2010) Expanding the use of neurotoxins in facial aesthetics: a consensus panel’s assessment and recommendations. J Drugs Dermatol 9(1):s7–s22 quiz s23–s25

    PubMed  Google Scholar 

  7. Carruthers A, Carruthers J, Cohen J (2003) A prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in female subjects with horizontal forehead rhytides. Dermatol Surg 29:461–467

    Article  PubMed  Google Scholar 

  8. Carruthers J, Fagien S, Matarasso SL (2004) Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 114(6):1S–22S

    PubMed  Google Scholar 

  9. Nestor MS, Ablon GR (2011) Duration of action of abobotulinumtoxinA and onabotulinumtoxinA: a randomized, double-blind study using a contralateral frontalis model. J Clin Aesthet Dermatol 4:43–49

    PubMed  Google Scholar 

  10. Benedetto AV (ed) (2006) Botulinum toxin in clinical dermatology. Taylor and Francis, Milton Park

    Google Scholar 

  11. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS (1998) An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg 124:1315–1320

    Article  PubMed  CAS  Google Scholar 

  12. Benedetto AV, Lahti JG (2005) Measurement of the anatomic position of the corrugator supercilii. Dermatol Surg 31(8 Pt 1):923–927

    PubMed  CAS  Google Scholar 

  13. Cook BE Jr, Lucarelli MJ, Lemke BN (2001) Depressor supercilii muscle: anatomy, histology, and cosmetic implications. Ophthal Plast Reconstr Surg 17:404–411

    Article  PubMed  Google Scholar 

  14. Clauser L, Tieghi R, Galie M (2006) Palpebral ptosis: clinical classification, differential diagnosis, and surgical guidelines: an overview. J Craniofac Surg 17:246–254

    Article  PubMed  Google Scholar 

  15. Troilius C (2004) Subperiosteal brow lifts without fixation. Plast Reconstr Surg 114:1595–1603 discussion 1604–1605

    PubMed  Google Scholar 

  16. Ezure T, Amano S (2010) The severity of wrinkling at the forehead is related to the degree of ptosis of the upper eyelid. Skin Res Technol 16:202–209

    Article  PubMed  Google Scholar 

  17. Finsterer J (2003) Ptosis: causes, presentation, and management. Aesthetic Plast Surg 27:193–204

    Article  PubMed  Google Scholar 

  18. Lepore FE (1988) Unilateral ptosis and Hering’s law. Neurology 38:319–322

    Article  PubMed  CAS  Google Scholar 

  19. Bartley GB, Lowry JC, Hodge DO (1996) Results of levator-advancement blepharoptosis repair using a standard protocol: effect of epinephrine-induced eyelid position change. Trans Am Ophthalmol Soc 94:165–173 discussion 174–177

    PubMed  CAS  Google Scholar 

  20. Lowe NJ, Shah A, Lowe PL, Patnaik R (2010) Dosing, efficacy, and safety plus the use of computerized photography for botulinum toxins type A for upper facial lines. J Cosmet Laser Ther 12:106–111

    Article  PubMed  Google Scholar 

  21. Hexsel D, Spencer JM, Woolery-Lloyd H, Gilbert E (2010) Practical applications of a new botulinum toxin. J Drugs Dermatol 9(3):s31–s37

    PubMed  Google Scholar 

  22. Carruthers A, Carruthers J (2009) A single-center dose-comparison study of botulinum neurotoxin type A in females with upper facial rhytids: assessing patients’ perception of treatment outcomes. J Drugs Dermatol 8:924–929

    PubMed  Google Scholar 

  23. Carruthers A, Carruthers J (2009) A single-center, dose-comparison, pilot study of botulinum neurotoxin type A in female patients with upper facial rhytids: safety and efficacy. J Am Acad Dermatol 60:972–979

    Article  PubMed  Google Scholar 

  24. Karsai S, Adrian R, Hammes S, Thimm J, Raulin C (2007) A randomized double-blind study of the effect of Botox and Dysport/Reloxin on forehead wrinkles and electromyographic activity. Arch Dermatol 143:1447–1449

    Article  PubMed  Google Scholar 

  25. Nestor MS, Ablon GR (2011) Comparing the clinical attributes of abobotulinumtoxinA and onabotulinumtoxinA utilizing a novel contralateral frontalis model and the Frontalis Activity Measurement Standard. J Drugs Dermatol 10:1148–1157

    PubMed  CAS  Google Scholar 

  26. Nestor MS, Ablon GR (2011) The Frontalis Activity Measurement Standard: a novel contralateral method for assessing botulinum neurotoxin type-A activity. J Drugs Dermatol 10:968–972

    PubMed  Google Scholar 

  27. Binder WJ (2006) Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison in identical twins. Arch Facial Plast Surg 8:426–431

    Article  PubMed  Google Scholar 

  28. de Boulle K (2008) Patient satisfaction with different botulinum toxin type A formulations in the treatment of moderate to severe upper facial rhytids. J Cosmet Laser Ther 10:87–92

    Article  PubMed  Google Scholar 

  29. Ghalamkarpour F, Robati RM, Aryanejad F, Toossi P (2010) Supraciliary wrinkles and botulinum toxin A. Clin Exp Dermatol 35:388–391

    Article  PubMed  CAS  Google Scholar 

  30. Hevia O (2010) Retrospective review of 500 patients treated with abobotulinumtoxinA. J Drugs Dermatol 9:1081–1084

    PubMed  Google Scholar 

  31. Hsu TS, Dover JS, Arndt KA (2004) Effect of volume and concentration on the diffusion of botulinum exotoxin A. Arch Dermatol 140:1351–1354

    Article  PubMed  CAS  Google Scholar 

  32. Levy JL, Pons F, Jouve E (2006) Management of the ageing eyebrow and forehead: an objective dose-response study with botulinum toxin. J Eur Acad Dermatol Venereol 20:711–716

    Article  PubMed  CAS  Google Scholar 

  33. Manstein CH, Beidas OE (2011) Comparing clinical efficacy of Botox and Dysport in a small group of patients. Plast Reconstr Surg 128:26e–27e

    Article  PubMed  CAS  Google Scholar 

  34. Cliff SH, Judodihardjo H, Eltringham E (2008) Different formulations of botulinum toxin type A have different migration characteristics: a double-blind, randomized study. J Cosmet Dermatol 7:50–54

    Article  PubMed  Google Scholar 

  35. Flynn TC (2007) Botox in men. Dermatol Ther 20:407–413

    Article  PubMed  Google Scholar 

  36. Michaels BM, Csank GA, Ryb GE, Eko FN, Rubin A (2012) Prospective randomized comparison of onabotulinumtoxinA (Botox) and abobotulinumtoxinA (Dysport) in the treatment of forehead, glabellar, and periorbital wrinkles. Aesthet Surg J 32:96–102

    Article  PubMed  Google Scholar 

  37. Oliveira de Morais O, Matos Reis-Filho E, Vilela Pereira L, Martins Gomes C, Alves G (2012) Comparison of four botulinum neurotoxin type A preparations in the treatment of hyperdynamic forehead lines in men: a pilot study. J Drugs Dermatol 11:216–219

  38. Grimes PE, Shabazz D (2009) A four-month randomized, double-blind evaluation of the efficacy of botulinum toxin type A for the treatment of glabellar lines in women with skin types V and VI. Dermatol Surg 35:429–435 discussion 435–436

    Article  Google Scholar 

  39. Taylor SC, Callender VD, Albright CD, Coleman J, Axford-Gatley RA, Lin X (2012) AbobotulinumtoxinA for reduction of glabellar lines in patients with skin of color: post hoc analysis of pooled clinical trial data. Dermatol Surg 38:1804–1811

    Article  PubMed  CAS  Google Scholar 

  40. Levy LL, Emer JJ (2012) Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthetic Surg 5:121–132

    Article  Google Scholar 

  41. Maas C, Kane MA, Bucay VW, Allen S, Applebaum DJ, Baumann L, Cox SE, Few JW, Joseph JH, Lorenc ZP, Moradi A, Nestor MS, Schlessinger J, Wortzman M, Lawrence I, Lin X, Nelson D (2012) Current aesthetic use of abobotulinumtoxinA in clinical practice: an evidence-based consensus review. Aesthet Surg J 32(1):8S–29S

    PubMed  Google Scholar 

  42. Monheit GD, Lin X, Nelson D, Kane MA (2012) Consideration of muscle mass in glabellar line treatment with botulinum toxin type A. J Drugs Dermatol 11:1041–1045

    PubMed  CAS  Google Scholar 

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Disclosures

Craig Albright, PhD, Michael Theisen, PhD, and Robert Gatley, MD, of Complete Healthcare Communications, Inc., Chadds Ford, PA, provided editorial support for this manuscript, with funding from Medicis, Division of Valeant Pharmaceuticals. Z. Paul Lorenc is advisor or consultant for Medicis and Johnson & Johnson Pharmaceutical Research & Development, LLC. Stacy Smith has served as a consultant for Fibrocell Science, Galderma, Medicis, Miramar Labs, SkinMedica, and Suneva Medical, and has received grants for clinical research from Allergan, Fibrocell Science, Galderma, Medicis, Miramar Labs, Revance, SkinMedica, and Suneva Medical. Mark Nestor has served as an advisory board member for Medicis, Galderma, Genentech, Merz, and Beiersdorf; as a consultant for Medicis, Galderma, Ulthera, Transdermal, and Erchonia; as a research investigator for Medicis, Galderma, Ulthera, Transdermal, and Erchonia; and as a speaker for Ulthera. Diane Nelson is an employee of Medicis. Amir Moradi has served as a speaker, consultant, and advisory board member for Allergan, Medicis, Skin Medica, and Bioform-Merz, and as a speaker trainer for Sciton Lasers.

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Authors and Affiliations

  1. Lorenc Aesthetic Plastic Surgery Center, 983 Park Avenue, New York, NY, 10028, USA

    Z. Paul Lorenc

  2. Private Practice, Cardiff, CA, USA

    Stacy Smith

  3. Center for Clinical and Cosmetic Research, Aventura, FL, USA

    Mark Nestor

  4. Medicis, Division of Valeant Pharmaceuticals, Scottsdale, AZ, USA

    Diane Nelson

  5. Private Practice, 2023 W Vista Way Ste F, Vista, CA, USA

    Amir Moradi

Authors
  1. Z. Paul Lorenc
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  2. Stacy Smith
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  4. Diane Nelson
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Correspondence to Z. Paul Lorenc.

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Lorenc, Z.P., Smith, S., Nestor, M. et al. Understanding the Functional Anatomy of the Frontalis and Glabellar Complex for Optimal Aesthetic Botulinum Toxin Type A Therapy. Aesth Plast Surg 37, 975–983 (2013). https://doi.org/10.1007/s00266-013-0178-1

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  • DOI: https://doi.org/10.1007/s00266-013-0178-1

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