Michael A. C. Kane

Nonsurgical Treatment of Platysmal Bands with Injection of Botulinum Toxin A

Botulinum toxin A has been used therapeutically in humans for over 20 years for a variety of medical indications. For the past 7 years, the author has injected it for cosmetic purposes in a variety of muscles of the head and neck. Fifty patient-injections of the platysma muscle were performed in an attempt to correct platysmal banding. An improvement was seen in all patients who presented to the office for follow-up in a timely manner (44 injections). Results were limited by redundant skin. No incidence of dysphagia or airway obstruction was encountered. The only complication noted was bruising. Although at least a small improvement in platysmal banding was seen in all patients, in no patient was there evidence of lifting of the lower face. All results were temporary.

The Effect of Botulinum Toxin Injections on the Nasolabial Fold

The use of botulinum toxin A (Botox; Allergan, Irvine, Calif.) for cosmetic purposes was first described in the medical literature in 1992. The author has been using botulinum toxin A in his practice for cosmetic purposes since 1991. In May of 1992, he began using Botox for improvement of the nasolabial folds. An experience of over 1000 injections to the nasolabial folds in more than 200 unique patients is presented. Technique and selection criteria have changed greatly during the past 10 years, and this evolution is discussed. The keys to achieving adequate correction and satisfied patients when treating the nasolabial fold are proper diagnosis of what is causing the fold and careful patient selection.

Diplopia following transconjunctival blepharoplasty

The resurgence of popularity of the transconjunctival approach to lower eyelid fat removal as a component of cosmetic blepharoplasty has been highlighted by a number of publications in recent years. There has been, however, minimal discussion in the literature of the complications of this procedure. Although the mechanism of muscle injury is similar in transcutaneous and transconjunctival surgery, there is a much more direct route to the inferior extraocular musculature via the latter approach. Herein, we present a series of six patients with diplopia status post-transconjunctival lower eyelid blepharoplasty referred to the Manhattan Eye, Ear, and Throat Hospital for evaluation. Transconjunctival lower lid blepharoplasty was performed as a primary procedure in four patients and as a secondary procedure following transcutaneous blepharoplasty in two patients. Patients were evaluated with ocular examination and orthoptic measurements. Magnetic resonance imaging was obtained in two cases. The inferior rectus and inferior oblique muscles were found to be equally injured in these cases (4 of 6), and the lateral rectus was encountered in one case. Two patients required strabismus surgery to correct their diplopia, whereas four patients improved with observation alone. The possible etiologies of postoperative diplopia following transconjunctival lower lid blepharoplasty are manifold. Mechanisms of extraocular muscle injury may include intramuscular hemorrhage and edema, cicatricial changes within the muscle, and accidental incorporation of extraocular muscle in closure of orbital septum. Avoidance of these complications is probably best achieved through intimate understanding on the part of the surgeon of eyelid anatomy from the transconjunctival perspective.

Classification of crow's feet patterns among Caucasian women: the key to individualizing treatment.

One of the most common complaints of aging patients is the appearance of crow’s feet lines in the lateral canthal region. Many different treatment methods, including chemical peels, surgical procedures, filler material injections, botulinum toxin injections, and laser resurfacing, have been used for effacement of these lines among aging patients and patients with sun damage. Despite the fact that many scientific articles have been written regarding the treatment of crow’s feet lines, the actual patterns of these lines have not been adequately studied or classified. Several different patterns of animation in this area have been observed. These different patterns and their frequencies are described. All crow’s feet patterns are not the same, and it follows that treatment of different patterns of crow’s feet lines should be adapted to the particular patterns.

Nonsurgical Treatment of Platysma Bands with Injection of Botulinum Toxin A Revisited

In this follow-up clinic to my article entitled “Nonsurgical Treatment of Platysma Bands with Injection of Botulinum Toxin A,”1 I discuss my experience using botulinum toxin type A in the neck for the last 4 years, especially in light of the other botulinum toxin neck article published in the same issue by Matarasso et al.2 Some stark differences between the two articles prompted me to vary my technique in the search for better results. Matarasso et al.2 recommended doses of up to 250 U per neck; my maximum dose was 40 U. The other study reported dysphagia and neck weakness; mine did not. The other study reported cosmetic improvement in the jowls; mine did not. The other study reported that unless skin laxity was rated as severe, there were better results with moderate skin laxity than with minimal skin laxity. This was exactly the opposite of the conclusion of my article. Their results included a 98.5 percent good to excellent result in patients with moderate horizontal neck rhytides, thick platysma bands, and moderate skin laxity. I offered no such numbers in my article, but I can tell you that even in my most optimistic moments with patients who had the most favorable outcomes (minimal skin laxity), my results were nowhere near the 90th percentile. The other article detailed 1500 closely followed patients who had their results categorized as poor, fair, good, or excellent. Mine contained only 50 injections in 26 unique patients. The Discussion following my article was fairly negative.3 The discussant stated that the reason for my suboptimal results compared with the results of Matarasso et al. may have been my relatively lower dosages. Due to the obvious weight of the scientific evidence of the other article, I pushed the envelope and began using some higher doses in necks with more excess skin. The results were not encouraging in my hands. I have now injected more than 2000 necks myself, and I am reporting that I have not changed a single thing since my initial article. I still do not believe that injecting the neck will give you a lower face lift. My average dose range for each platysma band is 7.5 to 12.5 U. The maximum dose that I have injected into a neck during the last 3 years has been 30 U. The best patients for injection are still patients with relatively strong platysma bands with minimal skin excess. In my original article, I stressed the two main windows where this condition was found: in relatively young women (mid-thirties to early forties) who are just beginning to see platysma banding, and in the older patient (any age) who no longer has a relative excess of neck skin due to a prior surgical procedure. The only thing I would add to my original article is a third, smaller category. This category contains younger women (mid-twenties and older) who have had a fat removal procedure in their neck that has now exposed their underlying bands. Obviously, this can occur with an overaggressive fat resection, but even a judicious removal of fat in some patients can bring about the first appearance of platysma bands. Thicker, male skin is somewhat protective of this occurrence. I would caution anyone

The effect of botulinum toxin injections on the nasolabial fold. Discussion

The use of botulinum toxin A (Botox; Allergan, Irvine, Calif.) for cosmetic purposes was first described in the medical literature in 1992. The author has been using botulinum toxin A in his practice for cosmetic purposes since 1991. In May of 1992, he began using Botox for improvement of the nasolabial folds. An experience of over 1000 injections to the nasolabial folds in more than 200 unique patients is presented. Technique and selection criteria have changed greatly during the past 10 years, and this evolution is discussed. The keys to achieving adequate correction and satisfied patients when treating the nasolabial fold are proper diagnosis of what is causing the fold and careful patient selection.