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Diagnosis and treatment of scarring alopecia

Key points Scarring alopecia is characterized by inflammation that leads to destruction of the pilosebaceous unit and ultimately the replacement of subcutaneous tissue with fibrous tracts. As a result, the hair loss can be disfiguring and cause significant distress in affected patients. Although treatment strategies for scarring alopecia center on disease subtype, the primary goal of treatment is to reduce the underlying inflammation causing the destruction…

Ethnic differences in hair

Key points Understanding the differences in hair structure and haircare practices in African Americans compared with white, Hispanic, and Asian patients is essential when evaluating and treating hair concerns in this population. Structural characteristics of Afro-textured hair include a retroverted hair bulb, an S-shaped follicle, and an elliptical-shaped hair shaft. Hairstyles such as tight buns and ponytails, braids, dreadlocks, and weaves increase the risk of developing…

Medical workup for hair loss

Key points Although most patients seeking hair restoration have androgenetic alopecia, there are several other potential etiologies of hair-loss disorders. It is important to exclude other causes of hair loss resembling androgenetic alopecia before considering cosmetic treatment. The comprehensive initial assessment of a patient seeking cosmetic hair restoration includes obtaining a full medical history, assessing risk factors for alopecia, performing a global and dermoscopic examination of…

Neuromodulator immunogenicity

Summary and key features All Botulinum toxin A preparations are immunogenic, and the degree of immunogenicity depends on their biologic structure, formulations, patient-specific factors, and genetic predisposition. The potential ramifications of immunogenicity can manifest clinically in various ways, ranging from no clinical implications to decreased therapeutic efficacy. The primary distinction between the various immunogenicity assay methodologies is their sensitivity and specificity. In the case of suspected…

The future of neuromodulators in aesthetic medicine

Summary and key features Aesthetic use of botulinum toxin type A (BoNT-A) started in the glabella and upper face but has now expanded into the mid and lower face, including masseters and neck. Aesthetic facial shaping of the upper and lower face is possible and popular with the combined use of BoNT-A and three-dimensional fillers, as well as laser and energy-based devices. New developments in the…

Botulinum toxin for the treatment of palmoplantar hyperhidrosis

Summary and key features Palmar and plantar hyperhidrosis can significantly impact quality of life. Botulinum toxin can produce hypohidrosis of the palms and soles for up to 6 months. Pain control is the greatest challenge for this method of treatment: ice or cooling devices are well tolerated modes of anesthesia for the hands; regional nerve blocks may also be used. Injections should be spaced 1 to…

Treatment of focal axillary hyperhidrosis with neuromodulators (and non-axillary regions)

Summary and key features Botulinum toxin (BoNT) is a safe, well-established, and effective treatment for focal axillary hyperhidrosis (HH). Key Features Sweating is the normal physiologic response to increased body temperature and is the primary avenue of heat loss during exercise or passive heat stress. HH describes excess sweating beyond what is necessary for thermoregulation. HH is classified as generalized or focal. The prevalence of HH…

Combination noninvasive facial aesthetic treatments with botulinum toxin type A

Summary and key features The multifactorial etiology of facial aging makes combination treatments logical and more successful than monotherapy. Thorough knowledge of facial anatomy is essential for safe and effective treatments. Botulinum toxin type A (BoNT-A) enhances the positive effects of three-dimensional fillers; energy-based devices such as intense pulsed light, broadband light, radiofrequency, and microfocused ultrasound; as well as nonablative/ablative laser treatments and surgery. Neocollagenesis is…

Treatment of darker skin types with neuromodulators

Summary and key features Botulinum toxin is a safe and effective procedure in darker skin types. In general, efficacy and safety profiles are similar to lighter skin types. With appropriate use, side effects are uncommon. Commonly treated areas are glabellar, horizontal forehead and periocular lines. Introduction Demographic trends coupled with the increased availability of minimally invasive treatment options have resulted in an increasingly diverse patient population…

The masseters: Hypertrophy, bruxism, and facial shaping with botulinum toxin

Summary and key features The masseter is a powerful muscle of mastication with both aesthetic and functional significance. Masseteric hypertrophy may be associated with bruxism and facial pain syndromes. Botulinum toxin may be used to reduce masseter muscle bulk to nonsurgically shape the lower face. Botulinum toxin may be used to decrease masseter muscle clenching power, potentially alleviating parafunctional grinding and clenching. Knowledge of anatomy and…

Platysma, nefertiti lift, and beyond

Summary and key features The aging lower face and neck are characterized by a number of features, including loss of jawline contour, vertical banding, horizontal line formation, dyschromia and texture complaints, tissue redundancy, and loss of elasticity. The aging neck is a growing concern among patients and has become as bothersome as lateral canthal lines. The role of the platysma in the aging of the lower…

Treatment of orbicularis oris, mentalis, depressor anguli oris with neuromodulators

Summary and key features The aging lower face is characterized by perioral rhytides, flattening of the lips, development of deep marionette lines, oral commissures, and pebbling of the chin. While its use is currently off-label for the lower face, botulinum toxin type A has been successfully used for lower facial rejuvenation. Treatment of the lower face targeting the orbicularis oris, mentalis, and depressor anguli oris with…

Treatment of the midface with botulinum toxin

Introduction The midface is the area of the face between the glabella and the subnasal region. It has a complex muscular anatomy, demanding full anatomic knowledge and a precise injection technique. The small muscles in this area are important for social interaction as they are involved in critical functions that express emotions. These include the orbital portion of the orbicularis oculi, zygomaticus major (ZM) and minor,…

Treatment of infraorbital/upper and lower eyelids with neuromodulators

Summary and key features Botulinum toxin is a common treatment for periorbital rhytides. Excellent cosmetic outcomes and avoidance of adverse events relies on an in-depth knowledge of periocular anatomy, age-related changes, and expert technique. Botulinum toxin may also be used for lid ptosis, malposition, and assymetry through purposeful dosing and precise placement. Periorbital Botulinum toxin is especially useful in combination with other cosmetic treatments such as…

Treatment of crow’s feet

Summary and key features Treatment of crow’s feet with botulinum toxin is safe and effective. Preoperative assessment of the periocular region, including analysis of dynamic and static rhytides, lower lid laxity, and upper lid ptosis, can improve the precision and safety of treatments. Stretching the skin and good lighting can help to avoid injection into superficial vessels to decrease the risk of bruising. Superficial injections into…

Shaping the eyebrow and upper face (palpebral aperture) with neuromodulators

The periorbital region Introduction The eyes and the periorbital area comprise a complex region consisting of many parts that all contribute to the attractiveness of the feature. One part of this area is the brow. The brow is our entrance to the eye area, dominating the upper face. It is a key beauty characteristic giving rise to entire brow industries. However, it is difficult to comprehend…

Treatment of frontalis and horizontal forehead lines with neuromodulators

Summary and key features Frontalis muscle properties (force, height, and length) influence neuromodulator treatment. When performing neuromodulator treatment of the frontalis muscle, priority should be placed on brow height over brow shape. Neuromodulator injection grid maps providing a “guide” for treating all patients should be avoided in routine clinical practice. Introduction The brow, defined here as the intersection of the forehead and upper eyelids, is the…

Treatment of glabellar lines with neuromodulators

Summary and key features Botulinum toxin type A (BoNT-A) for treatment of glabellar rhytides was US Food and Drug Administration (FDA) approved for cosmetic use in 2002 but has been used for this purpose since the early 1990s. Injection of botulinum toxin into the glabellar complex (corrugator supercilii and procerus muscles) and the lateral eyebrow may reduce glabellar and lower forehead rhytides and achieve a brow…

Benzyl alcohol

Summary and key features Benzyl alcohol has anesthetic effects and is safe for skin injection. Skin injection of botulinum toxin reconstituted with preserved (i.e., benzyl alcohol-containing) saline is less painful than injection of toxin reconstituted with saline only. Skin preinfiltration with preserved saline reduces pain associated with intravenous (IV) cannulation at the same site. Pain associated with skin injection of preserved saline is comparable to that…

Reconstitution and dilution

Summary and key features Most neuromodulators are provided as powders that require reconstitution prior to use. Preserved saline is the most common diluent used in clinical practice; however, other diluents have also proven to be safe and effective. While package inserts state that reconstituted botulinum toxin should be used within 4 to 24 hours, stored at 2°C to 8°C, and not refrozen, these recommendations are strict.…