Aim for modulation with neurotoxin injections

BOSTON – When it comes to chemical denervation, it is best to aim for modulation rather than paralysis, according to Anthony Rossi, MD.

Showing an image of a woman making an exaggerated facial expression, he noted that her treatment had left her overparalyzed in certain areas while other areas were moving. “It’s hard to figure out what she’s trying to emote and what she’s trying to express,” Dr. Rossi of Memorial Sloan Kettering Cancer Center, New York, said at the American Academy of Dermatology summer meeting.

“When we think about facial expressions and when we think about muscles, they work in tandem together, so if things are overparalyzed then some muscles won’t work while others will take over and it will create a perplexed look,” he explained.

A computer analysis of college students demonstrating various facial expressions that represent different emotions identified 21 unique expressions that used a combination of muscles that were different from all other expressions. “There were 6 basic expressions and 15 compound expressions. So as humans, we just need to know we’re using all these facial muscles to convey our message to the world,” Dr. Rossi said.

This finding has particular implications when treating younger versus older patients, he noted.

Younger patients are coming in for cosmetic procedures in increasing numbers, and use of chemical denervation in these patients, compared with in older patients, may be more likely to change facial expressions and appearance. “In the older patient, it may be appropriate to do more cosmetic procedures, but in the younger patient, even the tiniest amount of change can really have a drastic effect on their look,” he said.

As with any surgical or cosmetic case, good patient selection is important for improving patient satisfaction, as is management of patient expectations, he added.

Dr. Rossi compared photos of two women, both in their 40s. One was toxin naive, but the other – despite having scleroderma and undergoing chemotherapy for breast cancer – looked much more “refreshed.” The difference was that the second patient received regular filler and neurotoxin injections, he explained.

To achieve a comparable cosmetic result in the toxin-naive patient, multiple procedures are needed, and procedures should be staged over time, he said.

He noted that it is important to take photos to show patients; photos look different from a mirror image. In addition, static and dynamic rhytids will respond differently to treatment, he pointed out. Static, etched-in rhytids may take longer to correct and may require repeat injections, whereas dynamic rhytids will respond well to neurotoxins, he added.

Combination treatments, such as those incorporating fillers and/or laser resurfacing, may also be needed. “I like to stage my cosmetic procedures,” he said. Staging may not always be possible, but he prefers to allow 2 weeks for a neurotoxin to take effect before adding more neurotoxin or filler.

Among other “pearls” that Dr. Rossi offered for improving outcomes and patient satisfaction were warning patients in advance that static rhytids may require filler in addition to neurotoxin injection, checking for and photographing baseline asymmetry (such as a crooked smile) prior to treatment to avoid blaming the treatment after the fact, and tailoring injections to the patient.

For example, for a particularly expressive individual, it is important to maintain natural movement. For this type of patient, “a standard injection pattern may not work. You still want to give her some natural movement,” he said, explaining that the injection pattern in such a patient would “be more unique, more spread out.

“I usually use multiple rows of injections, but I tend to keep the units that I’m using at a lower dosage so there is some movement, and we don’t drop her brow too much,” he said.

A possible aesthetic trend toward more natural movement – “less frozen, less paralysis” – was suggested by a 2015 retrospective chart review, led by Alastair Carruthers, MD, of the University of British Columbia, Vancouver, showing a decreasing number of units of onabotulinumtoxinA being used over time. In 5,112 treatment sessions in 194 patients over an average of 9 years, the mean dose for forehead lines steadily decreased over time (Dermatol Surg. 2015 Jun;41[6]:693-701).

Dr. Rossi disclosed that he has served on an advisory board for Allergan.

sworcester@frontlinemedcom.com

BOSTON – When it comes to chemical denervation, it is best to aim for modulation rather than paralysis, according to Anthony Rossi, MD.

Showing an image of a woman making an exaggerated facial expression, he noted that her treatment had left her overparalyzed in certain areas while other areas were moving. “It’s hard to figure out what she’s trying to emote and what she’s trying to express,” Dr. Rossi of Memorial Sloan Kettering Cancer Center, New York, said at the American Academy of Dermatology summer meeting.

“When we think about facial expressions and when we think about muscles, they work in tandem together, so if things are overparalyzed then some muscles won’t work while others will take over and it will create a perplexed look,” he explained.

A computer analysis of college students demonstrating various facial expressions that represent different emotions identified 21 unique expressions that used a combination of muscles that were different from all other expressions. “There were 6 basic expressions and 15 compound expressions. So as humans, we just need to know we’re using all these facial muscles to convey our message to the world,” Dr. Rossi said.

This finding has particular implications when treating younger versus older patients, he noted.

Younger patients are coming in for cosmetic procedures in increasing numbers, and use of chemical denervation in these patients, compared with in older patients, may be more likely to change facial expressions and appearance. “In the older patient, it may be appropriate to do more cosmetic procedures, but in the younger patient, even the tiniest amount of change can really have a drastic effect on their look,” he said.

As with any surgical or cosmetic case, good patient selection is important for improving patient satisfaction, as is management of patient expectations, he added.

Dr. Rossi compared photos of two women, both in their 40s. One was toxin naive, but the other – despite having scleroderma and undergoing chemotherapy for breast cancer – looked much more “refreshed.” The difference was that the second patient received regular filler and neurotoxin injections, he explained.

To achieve a comparable cosmetic result in the toxin-naive patient, multiple procedures are needed, and procedures should be staged over time, he said.

He noted that it is important to take photos to show patients; photos look different from a mirror image. In addition, static and dynamic rhytids will respond differently to treatment, he pointed out. Static, etched-in rhytids may take longer to correct and may require repeat injections, whereas dynamic rhytids will respond well to neurotoxins, he added.

Combination treatments, such as those incorporating fillers and/or laser resurfacing, may also be needed. “I like to stage my cosmetic procedures,” he said. Staging may not always be possible, but he prefers to allow 2 weeks for a neurotoxin to take effect before adding more neurotoxin or filler.

Among other “pearls” that Dr. Rossi offered for improving outcomes and patient satisfaction were warning patients in advance that static rhytids may require filler in addition to neurotoxin injection, checking for and photographing baseline asymmetry (such as a crooked smile) prior to treatment to avoid blaming the treatment after the fact, and tailoring injections to the patient.

For example, for a particularly expressive individual, it is important to maintain natural movement. For this type of patient, “a standard injection pattern may not work. You still want to give her some natural movement,” he said, explaining that the injection pattern in such a patient would “be more unique, more spread out.

“I usually use multiple rows of injections, but I tend to keep the units that I’m using at a lower dosage so there is some movement, and we don’t drop her brow too much,” he said.

A possible aesthetic trend toward more natural movement – “less frozen, less paralysis” – was suggested by a 2015 retrospective chart review, led by Alastair Carruthers, MD, of the University of British Columbia, Vancouver, showing a decreasing number of units of onabotulinumtoxinA being used over time. In 5,112 treatment sessions in 194 patients over an average of 9 years, the mean dose for forehead lines steadily decreased over time (Dermatol Surg. 2015 Jun;41[6]:693-701).

Dr. Rossi disclosed that he has served on an advisory board for Allergan.

sworcester@frontlinemedcom.com

BOSTON – When it comes to chemical denervation, it is best to aim for modulation rather than paralysis, according to Anthony Rossi, MD.

Showing an image of a woman making an exaggerated facial expression, he noted that her treatment had left her overparalyzed in certain areas while other areas were moving. “It’s hard to figure out what she’s trying to emote and what she’s trying to express,” Dr. Rossi of Memorial Sloan Kettering Cancer Center, New York, said at the American Academy of Dermatology summer meeting.

“When we think about facial expressions and when we think about muscles, they work in tandem together, so if things are overparalyzed then some muscles won’t work while others will take over and it will create a perplexed look,” he explained.

A computer analysis of college students demonstrating various facial expressions that represent different emotions identified 21 unique expressions that used a combination of muscles that were different from all other expressions. “There were 6 basic expressions and 15 compound expressions. So as humans, we just need to know we’re using all these facial muscles to convey our message to the world,” Dr. Rossi said.

This finding has particular implications when treating younger versus older patients, he noted.

Younger patients are coming in for cosmetic procedures in increasing numbers, and use of chemical denervation in these patients, compared with in older patients, may be more likely to change facial expressions and appearance. “In the older patient, it may be appropriate to do more cosmetic procedures, but in the younger patient, even the tiniest amount of change can really have a drastic effect on their look,” he said.

As with any surgical or cosmetic case, good patient selection is important for improving patient satisfaction, as is management of patient expectations, he added.

Dr. Rossi compared photos of two women, both in their 40s. One was toxin naive, but the other – despite having scleroderma and undergoing chemotherapy for breast cancer – looked much more “refreshed.” The difference was that the second patient received regular filler and neurotoxin injections, he explained.

To achieve a comparable cosmetic result in the toxin-naive patient, multiple procedures are needed, and procedures should be staged over time, he said.

He noted that it is important to take photos to show patients; photos look different from a mirror image. In addition, static and dynamic rhytids will respond differently to treatment, he pointed out. Static, etched-in rhytids may take longer to correct and may require repeat injections, whereas dynamic rhytids will respond well to neurotoxins, he added.

Combination treatments, such as those incorporating fillers and/or laser resurfacing, may also be needed. “I like to stage my cosmetic procedures,” he said. Staging may not always be possible, but he prefers to allow 2 weeks for a neurotoxin to take effect before adding more neurotoxin or filler.

Among other “pearls” that Dr. Rossi offered for improving outcomes and patient satisfaction were warning patients in advance that static rhytids may require filler in addition to neurotoxin injection, checking for and photographing baseline asymmetry (such as a crooked smile) prior to treatment to avoid blaming the treatment after the fact, and tailoring injections to the patient.

For example, for a particularly expressive individual, it is important to maintain natural movement. For this type of patient, “a standard injection pattern may not work. You still want to give her some natural movement,” he said, explaining that the injection pattern in such a patient would “be more unique, more spread out.

“I usually use multiple rows of injections, but I tend to keep the units that I’m using at a lower dosage so there is some movement, and we don’t drop her brow too much,” he said.

A possible aesthetic trend toward more natural movement – “less frozen, less paralysis” – was suggested by a 2015 retrospective chart review, led by Alastair Carruthers, MD, of the University of British Columbia, Vancouver, showing a decreasing number of units of onabotulinumtoxinA being used over time. In 5,112 treatment sessions in 194 patients over an average of 9 years, the mean dose for forehead lines steadily decreased over time (Dermatol Surg. 2015 Jun;41[6]:693-701).

Dr. Rossi disclosed that he has served on an advisory board for Allergan.

sworcester@frontlinemedcom.com