In 1992, Jean Carruther and Alastair Carruthers in Canada first reported the use of botulinum toxin type A (hereinafter referred to as BTXA) for the treatment of crow’s feet and forehead lines, since then the method has been gradually promoted in North America and Western Europe, in April 2000 the Canadian government approved BTXA for the treatment of wrinkles, and in April 2002 the US FDA approved BTXA for the treatment of wrinkles, the author injected 1151 cases of crows feet, frown lines, forehead lines and bite muscle hypertrophy from August 2003 to May 2010, with significant efficacy, high safety and mild side effects. The author observed adverse reactions after injection, mainly manifested as abnormal facial expression, which is also the most likely to cause medical disputes after injection. After years of clinical observation and practice, the author has summarized a series of strategies to avoid or reduce abnormal facial expressions, which I would like to share with my colleagues to reduce disputes.
1. Pre-injection communication skills
BTXA injection is simple and convenient compared to cosmetic surgery, with little trauma and no need for special care. Therefore, some doctors in the clinic are prone to paralysis, and inject hastily without sufficient communication, or even exaggerate the cosmetic efficacy before injection, without informing the patient that abnormal expressions may occur, resulting in such adverse reactions after the drug takes effect and causing disputes. The expression abnormalities caused by different injection sites are also different, and the following communication skills for each injection site are described in detail.
1.1 Crow’s feet
The wrinkles on the lateral side of the eye orbit, commonly known as fishtail lines, are stripes of varying thickness and are arranged radially along the outer canthus, and the texture is more obvious due to contraction of the orbicularis oculi muscle when closing the eyes with force or laughing. As the skin elasticity decreases with age, the crow’s feet will gradually deepen and extend slightly to the sides. The formation of crow’s feet is closely related to the orbicularis oculi muscle, mainly due to the contraction of the orbicularis oculi lateralis muscle, that is, the orbital area, in addition to the role of photoaging, both expression lines and photoaging, its treatment is a little more difficult, but the use of BTXA injection treatment still has a good effect.
Since the contraction of the orbicularis oculi muscle is restricted after injection, the contraction of this muscle becomes smaller when smiling, which is prone to smile stiffness, bitter smile and other manifestations. At this time, attention should be paid to preoperative communication skills, both to inform the patient of the possible postoperative conditions and to make him understand that this stiffness only appears when smiling; it is not visible when smiling and not making expressions. Moreover, the change in expression will gradually disappear and return to normal with time (about 1~2 months). The author found in the clinic that patients with different facial structures have different chances and degrees of smile stiffness after injection. Patients with higher cheekbones or thicker cheek muscles rarely or do not have smile stiffness, and even if it occurs, it is so slight that patients or their friends and relatives hardly notice it; while patients with flatter cheekbones are prone to smile stiffness and unnaturalness after surgery. Therefore, the change of expression should be predicted as accurately as possible according to the patient’s facial structure, and it is necessary to make them understand the role of wrinkle removal as well as to fully understand the change of expression in order to effectively avoid disputes.
In addition, many patients may mistakenly think that the expression of stiffness means that the skin around the eyes feels hard to touch and the texture is like rubber, but in fact, it is not. We must patiently explain that it only looks like the smile amplitude becomes smaller and looks stiff, but it is still soft skin to touch to eliminate the patient’s fear.
1.2 Interbrow lines
The interbrow lines are located between the two eyebrows, mostly 2~3, mainly in a vertical direction, and the lower part is often separated to the sides in the shape of “eight”, perpendicular to the direction of the interbrow muscle fibers. They are produced by the synergy of four muscles: the frown muscle, the descending brow muscle, the upper muscle fiber of the orbicularis oculi muscle and the lower edge of the frontalis muscle. The wrinkles mainly show angry expressions, causing the eyebrows to move inward, and over time, “Sichuan” lines and even nasal dorsal lines appear.
The effect of BTXA injection is mainly on the frown muscle and the descending brow muscle, which is very effective in improving the wrinkles, especially in young patients (25~40 years old), and the effect is better in female patients than in male patients. Because the lower edge of the frontalis muscle plays a role in the formation of interbrow lines in some patients, so after injection, such patients are prone to the performance of static eyebrows and excessively high eyebrow tips, especially when emotionally agitated, the two sides of the eyebrow tips hang high, giving people a fierce and irritable feeling. Therefore, patients should be informed in advance before injection, and the reasons for such performance should be explained in detail, and the movement characteristics of the patient’s face, especially the frontal muscles, should be carefully observed to predict the possibility and degree of this situation.
In the communication with patients, I found that some patients have “eight” shaped eyebrows, and their faces look lethargic and lack of spirit, when they are told that such condition will occur after injection, the patients not only accept but also like such effect. Therefore, adequate communication before surgery can not only avoid disputes, but also provide a more detailed understanding of the patient’s needs and maximize the patient’s desire for beauty. In addition, the patient can be informed that in order to avoid such adverse reactions, the doctor will adjust the injection dose and site according to the individual differences of the patient when injecting (this issue is discussed in detail in the next heading), and the patient is told not to worry too much. Moreover, if the brow tip becomes elevated, there is no need to panic and the condition can still be corrected by injecting the drug above the already elevated brow tip.
1.3 Forehead lines
Frontal lines, commonly known as head-lift lines, are located between the upper part of the eyebrow and the eyebrow to the forehead hairline, arranged horizontally, due to the contraction of the frontalis muscle, which is perpendicular to the frontalis muscle fibers. The frontal lines are usually 3~6, divided into middle group and lateral group, the former is above the eyebrow, the latter is above the eyebrow, the two groups of frontal lines can be continuous or bifurcated, the lateral group is caused by the direct contraction of frontal muscle, the middle group is the result of both frontal muscles pulling the skin in the middle together. Frontal lines generally appear early, some people have appeared when they were teenagers, with the growth of age, the skin gradually aging, elasticity decline, frontal lines also deepen.
The frontal lines are caused by the contraction of frontal muscle, and the contraction of frontal muscle to lift the eyebrow is the main expression of the face, so the key to inject BTXA in the frontal area is only to weaken the power of frontal muscle, not to make the muscle completely paralyzed, so that the skin in the frontal area can be stretched, to keep the frontal muscle has a certain tension, with good expression function, otherwise after injection, there will be eyebrow drooping, eyebrow shape change (“eight “Otherwise, after injection, there will be adverse reactions such as eyebrow drooping, eyelid sagging, eye becoming smaller, upper eyelid puffiness, etc. If the injection amount is not the same on both sides, there will also be asymmetric performance with unequal height and shape of bilateral eyebrows, which obviously affects the patient’s normal expression, but due to individual differences, the strength of frontal muscle is different for each patient, and it is difficult to predict accurately before injection, so in addition to clearly informing the possible adverse reactions. Patients should also be asked to repeatedly do the action of raising eyebrows quickly to correctly judge the strength of frontalis muscle in order to inform the possibility of adverse reactions, so that patients can be psychologically prepared in advance, and of course, they should also understand that the doctor will pay attention to this point in the operation and will make appropriate adjustments in the dose and site, so there is no need to worry too much.
In addition, some patients in the consultation will be based on their own forehead lines, the injection site or the amount of advice, such as some patients with different severity of bilateral forehead lines, they put forward serious side want to increase the amount of drug requirements, in fact, is not right, then should be patient to explain the bilateral dose is not equal, may appear eyebrow height inconsistent side effects, try to avoid. Individual patients with forehead lines too close to the tip of the eyebrow, less than 1cm, these patients proposed to inject close to the tip of the eyebrow, which is also not right, should explain that this injection will lead to eyebrow downward pressure, eyelid edema, and even eyes become smaller and other side effects, must also be avoided. Therefore, the patient should be correctly guided during preoperative communication and try to meet his or her requirements without violating the principles of injection, rather than completely complying with the patient’s wishes in order to keep him or her.
1.4 Hypertrophy of the occlusal muscle
The occlusal muscle is roughly divided into two layers: the superficial layer starts from the zygomatic arch and ends at the angle of the mandible; the deep layer starts from the entire zygomatic arch up to the anterior end of the temporomandibular joint node and ends at the upper part of the lateral surface of the ascending branch of the mandible and the root of the rostral process. The bite muscle hypertrophy is usually accompanied by abnormal morphology of the mandible, forming a benign hypertrophy deformity of the bite muscle mandibular angle. The patient often has a “wind” or “use” face shape, and the lower third of the face is obviously wide. For patients with simple hypertrophy of the bite muscle, BTXA injections are effective; for patients with bony hypertrophy of the mandibular angle or cheek fat pad hypertrophy and fat hypertrophy, BTXA injections are only used as an adjunctive treatment.
The principle of BTXA injection for treatment of bite muscle hypertrophy is to make the contraction ability of the bite muscle decrease, disuse atrophy of muscle fibers, and volume reduction, so as to improve the contour of the purpose, while still being able to speak and daily eating, patients are satisfied with the effect after injection, but a few patients may also have abnormal expressions, manifested as a decline in the corners of the mouth when laughing, smile is not cheerful, nasolabial folds deepen; patients with dimples, the dimple shape becomes longer, or even disappears In patients with dimples, the dimple shape may become longer or even disappear. The author summarizes that the following groups of people are prone to such problems: 1. patients with thick cheek muscles and fat or thick cheek fat pads (commonly known as “baby fat”); 2. patients over 40 years old with poor skin elasticity in the cheeks; 3. patients with dimples; therefore, careful observation or manual diagnosis of the patient’s facial fat, skin elasticity, and dimples should be performed before injection. Understand whether patients mind the disappearance or deformation of dimples. There was once a case of a male patient who had a dimple in each cheek before surgery, and the author foresaw that the postoperative period might lead to deformation or disappearance of dimples, and the patient said he could accept it, and the result did disappear after injection. The patient not only did not mind, but also liked the dimple-free face very much, and thought he had increased his masculinity, just as he wished. Therefore, for patients prone to abnormal expressions, achieving preoperative consultation in place, adequate communication, and having words in advance can effectively alleviate patients’ concerns about the changes in expressions that occur after injection, fully understand the temporary nature of postoperative adverse reactions, and increase treatment satisfaction.
In a word, effective and adequate communication before injection plays a vital role in screening indications, avoiding medical disputes and improving patient satisfaction.
2. Selection of injectable drugs and injection techniques
First of all, it is pointed out that the selection of drugs should be careful. Since there are many informal products of Botox in the current drug market with different quality, and many complications and even deaths have occurred after surgery, it is necessary to introduce regular products through legal channels when selecting drugs. Otherwise, the dose of informal drugs is not accurate and can easily lead to adverse reactions. The following is still a breakdown of their injection techniques by site.
2.1 Crow’s feet
When injecting fishtail, the closer to the lower part of the outer corner of the eye and the closer to the zygomatic muscle, the easier it is to have a stiff smile, so the depth of the needle in this area should be shallower than the upper part of the outer corner of the eye (below the eyebrow) and the outer corner of the eye, and the dose should be less, especially for the first injection, you can choose half amount (regular dose of 4~5U per injection site, half amount of 2~2.5U), and the lower eyelid area is better not to be injected until the second injection, you can ask When the second injection is given, the patient can ask about the extent of the effect of the initial injection on the expression to decide whether the site is suitable for injection and the injection dose. For patients with thicker zygomatic muscles, this concern is not necessary.
2.2 Interbrow lines
The injection of interbrow lines should pay attention to try to enter the needle about 1cm above the eyebrow, not above the waist of the eyebrow, less than 1cm will overly depress the eyebrow, more than 1cm will affect the frontal muscle strength, eyebrow elevation is limited; if the patient’s frontal muscle strength is large and the eyebrow elevation itself is very active, one injection should be added at 2.5~3cm above each side of the eyebrow tip, and the dose should be reduced by half (regular dose 4~5U per point, half amount 2~ If the dose is large, it is easy to over-pressure the eyebrow tips, and the dose is small, it cannot prevent the eyebrow tips from being raised.
2.3 Forehead lines
Forehead lines injection needle location should pay attention to the distance between and eyebrow is better than 2cm, especially for patients with narrow forehead (eyebrow is less than 5cm from the front hairline), if the injection point is too close to the eyebrow, there will be obvious downward pressure on the eyebrow adverse reaction, individual patients even have difficulty opening their eyes, causing inconvenience in daily life. When injecting, two principles should be followed: 1. the dose should be slightly larger for the area near the center of the forehead than for both sides of the forehead (4~5U per injection point in the middle and 2~2.5U on both sides); 2. the curvature of the line connecting the injection points from the center of the forehead to both sides should be the same as the curvature of the eyebrow shape; in this way, the change of the eyebrow shape caused by the downward pressure of the eyebrow tip can be avoided as much as possible.
2.4 Hypertrophy of the bite muscle
When injecting bite muscle hypertrophy, attention should be paid to the needle location as close as possible to the angle of the jaw and away from the cheeks, especially away from the corners of the mouth on both sides, the total amount of bilateral injections should not be more than 100 U. Inject 2 points of bilateral bite muscles respectively, 20 U~30 U each time, too many times into the needle is likely to cause drug diffusion into the buccal muscle, causing abnormal expression.
In addition to the above injection techniques, for patients who receive injection for the first time, it is best to choose only one site for injection, and then gradually increase the sites as the number of injections increases, because the abnormal changes in expression caused by the injection of one site are very slight, and even not easy to notice, and when the sites are gradually increased later, the changes in expression also occur gradually without being aware of it, and there is an adaptation process for patients and their friends and relatives, which is also one of the ways to reduce disputes. This is one of the methods to reduce disputes.
3.Processing of abnormal expressions after injection
3.1 Active communication with patients
When expression abnormalities appear after injection, do not avoid the patient or shirk responsibility, at this time the patient is in a state of anxiety, should actively carry out ideological guidance, explain the temporary nature of abnormal changes in expression, most patients worry about whether they can return to normal, therefore, must clearly inform the patient that the abnormal expression can disappear in about 2 months or even 1 month, during this period try to avoid laughing and other violent expressions, most patients can Most patients can understand and cooperate. This shows that proper explanation and patient guidance can greatly reduce their worries and avoid disputes.
3.2 Correction of abnormal expressions with Botulinum toxin supplemental injections
After the injection of interbrow lines, if there is excessive elevation of bilateral brow tips and the patient feels aggressive expression, botulinum toxin can be reinjected 2~2.5U at 2.5~3cm directly above the bilateral brow tips respectively, and the eyebrows can be restored to the normal state. When treating abnormal expressions caused by crow’s feet, forehead lines and bite muscle hypertrophy, this method cannot be used to correct them and other methods need to be sought.
3.3 Other solutions
When expression abnormalities cannot be corrected by re-injection of botulinum toxin, the following can be tried: 1. local injection of neostigmine antagonism, 1~2mg/day, if the injection is ineffective for 3 consecutive days, stop the treatment and use other methods instead. 2. use appropriate techniques to massage the injected area to promote blood circulation, accelerate the metabolism of the drug, and promote the recovery of synaptic function, thus repairing the function of innervated muscle movement.
In summary, although BTXA injection is simple and the effect is immediate, the cosmetic surgeon should not be paralyzed in the mind and should pay attention to the strict selection of preoperative indications and good communication in order to minimize the adverse reactions of abnormal expression after injection.