 |
||
 |
|
|
The most often advertised cosmetic adjuct is Botox. Unfortunately the appropriate use of this agent is not always well understood by those administering the treatment (often non-physicians) nor their patients. What this modality can provide is a chemical forehead lift. Botox is better utilized in the younger cosmetic patient, less than 45 years old, as the cost of repeated injections, usually at 4 to 5 month intervals, can rapidly approach the cost of a traditional forehead lift. Well performed open forehead lifts (not the endoscopic short cut!) often produce an excellent result for 15 or more years.
The most common error in the use of Botox is attempting to erase the mid forehead wrinkles. This blocks the action of the only elevator of the brows thus negating the desired effect and producing a strangely "frozen" upper face. The injections should only be directed at the eyebrow depressor muscles around the eyes. Other less common uses are for lessening the upper lip wrinkles and the drooping corners of the mouth. Injections into the upper lip need to be very conservative.
At this time the use of Botox in selected cases of migraine is an accepted "off label" indication for the drug. These injections are generally placed at the anterior (front) hairline and into the area of maximal pain the posterior (back) neck muscle. The migraine patients for whom this is most effective are those who lie in the clinical spectrum between the "classic migraine" and the pure muscle contraction headache. These patients have a significant portion of their pain arising in the muscles surrounding the scalp.
The other commonly advertised agents are a variety of "fillers". These are best used to fill in the cheek-lip fold in those not ready for a facelift and for the "marionette" lines below the corners of the mouth. These agents should not be used for the "crows feet" around the eyes and should be used sparingly in the upper lip. Injections carefully positioned along the upper lip margins can produce a pleasing "pouting", but attempting to inject the vertical lip lines often produces less than the desired result and in fact may make the folds appear deeper. Deep lip wrinkles are best treated with peels the details of which may be discussed at consultation.