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Botulinum Toxin in Aesthetic Indications – Technique Follows Function
prompted many physicians without any knowledge of aesthetic The dose has to be adapted. When treating a patient for the first
medicine to offer various non-surgical aesthetic treatments, with time, you should weaken the muscle instead of paralysing it. After
the danger that aesthetic dermatology stands to lose its scientific the second or third treatment you can increase the dosage at each
relevance. Evidence-based medicine should be applied not only in injection point if required. A patient still complaining of having
medical procedures, but also in aesthetic dermatology. muscle activity is no mishap. You easily can add some units in a
second session two weeks later. However, a patient complaining of
Technique Follows Function a frozen look will be unhappy for the next few months. This patient
It is evident that you read all of the publications on a topic and that will not return and will be no good for your reputation.
you visit congresses and workshops before you begin to use a
particular aesthetic procedure. There are many textbooks (and the It is very important to be aware that most patients have an
number is increasing every year) dealing with botulinum toxin asymmetrical face and that the majority are not aware of this fact
treatments in aesthetic dermatology. It is essential to know every unless you tell him or her beforehand. Each patient closely inspects
detail onf the mechanism of action of the drug, the exact anatomy his or her face after therapy and attributes the newly discovered
of the treated area and the treatment clues before, during and after asymmetry to your aesthetic treatment. Due to the high costs of
botulinum toxin therapy before you start to inject your patients such treatments, patients have high expectations. All of these
with botulinum toxin A. Every beginner should remain on the factors make a standardised pre- and post-treatment plan
suggested protocols the experts recommend. After Glogau,
3
we indispensable. Precise and standardised information not only on
distinguish four types of wrinkles: the procedure, but also information about the side effects,
complications and risks, should be given to the patient before
• no wrinkles; treatment. In this consultation, you should highlight alternative
• wrinkles in motion; methods to the planned treatment.
• wrinkles at rest; and
• nothing but wrinkles. A demonstration using a mirror showing what is to be expected
and, even more importantly, what is not to be expected after
Stages 2 and 3 are the main indications for non-surgical treatment treatment is worthwhile, and photographic documentation
such as botulinum toxin injections, whereas stage 4 is more the before and after treatment is indispensible. Information given
field of plastic surgeons. Increasingly, the trend is to treat even before a treatment is a clarification; information given after the
patients in stage 1 in order to prevent deep wrinkling. As your treatment it is an excuse. Often neglected, the follow-up
experience grows, you will notice that for an excellent result it consultation is no less important. At the beginning of your learning
is insufficient to treat your patients according to a a strict, pre- curve it is essential to improve your skills by seeing the good and
determined pattern. As the aesthetic problem differs from patient sometimes not so good results. This gives you direction about
to patient, you must individualise your injection plan: technique upcoming treatments in general and individual cases in particular.
follows function. While it can be adequate to inject a young female Your patients will appreciate these controls because it leaves the
with only slight wrinkling in the glabella with the recommended impression that they are in good hands and being treated by a very
injection pattern (see Figure 1), it may be not satisfactory in a attentive doctor.
patient with deep wrinkling (see Figure 2) or patients with increased
muscle activity, such as men (see Figure 3). To achieve a curved If you treat your patients with the required accuracy, the accordant
eyebrow we have to choose a different injection plan from the one skills and the required willingness to solve side effects or
we would choose for a horizontal eyebrow. Patients with a distinct complications, you will have happy patients. If you follow these
physiological brow ptosis need different injection points and doses. suggestions and perform your treatments with enthusiasm, you will
Aesthetic dermatology – and botulinum toxin injections in treat your patients for the excellent result and not for the money. ■
particular – necessitate a profound understanding of anatomical
and physiological rules. Only if you are able to adapt your skills will
Oliver P Kreyden is President of the Swiss Group of
you achieve results that satisfy both the patient and the therapist.
Aesthetic Dermatology and Skincare (SGEDS), a
However, this means that you need to have improved knowledge faculty member of the European Group of
of aesthetic procedures and be willing to adapt your technique
Hyperhidrosis and President of the Swiss Faculty of
Hyperhidrosis. He runs a private practice,
to the function.
‘Methininserhof’, in Basel, with a particular emphasis
on aesthetic treatments and dermatological surgery.
Only Inject If You Like Doing It
Dr Kreyden has contributed to several textbooks on
botulinum toxin in dermatological indications and is
As your skills improve you will also deal with increasingly
editor of the textbook Hyperhidrosis and Botulinum Toxin in Dermatology. He has
challenging cases. Begin with simple cases and treat them after a written numerous articles and abstracts in professional journals and is a regular
set injection plan. Creating a lot of happy patients increases your
invited speaker and Chair at international conferences in the field of aesthetic
dermatology. Dr Kreyden is a Board Member and Advisory Board Member of
self-confidence and prevents you from a very dangerous
numerous societies, including the World Society of Anti-Aging Medicine (WOSAAM),
overconfidence. The aim is that both patients and doctors are the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), the
happy with the result. Below are some simple rules to help you to
European Academy of Dermatology and Venereology (EADV) and the American
Academy of Dermatology.
achieve this aim.
1. Springer IN, Wannicke B, Warneke PH, et al., Facial 2007;59:156–62. www.plasticsurgery.org
attractiveness: visual impact of symmetry increases 2. American Society of Plastic Surgeons, The 200/2005/2007 3. Glogau RG, Aesthetic and anatomic analyses of the ageing
significantly towards the midline, Ann Plast Surg, national plastic surgery statistics, 2007. Available at: skin, Semin Cutan Med Surg, 1996;15:134–8.
EUROPEAN DERMATOLOGY 45
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