.e Horizontal lines and glabella wrinkles are often difficult to remove surgi-
c cally. The forehead is made up of numerous mimicry muscles that can-
g not be entirely smoothed-out even following a brow lift (endoscopic,
5 coronal, or hairline cut). Botox is therefore an important resource for removing wrinkles in the forehead region. Patients are amazed at the results and even accept that the injections will have to be repeated after 4-6 months if they want to have a smooth forehead.
Botulinum toxin must be injected by an experienced doctor under sterile conditions in the clinic, with the treatment carried out as day-case surgery. Otherwise, significant complications may occur, including paralysis of the eyes. The preoperative marking of the injection sites is particularly important if adverse side effects are to be avoided. The patient should frown so that it is possible to see the area of maximum muscle activity. Particular care should be taken in the supraorbital region and lateral to the pupillary boundary (illustrations).
No more than 1.5 ml botulinum toxin, corresponding to 60 U of Botox, should be injected per session. Treatment should be repeated after 4 months at the earliest. It is safe to give three injections per year.
As the ampules supplied by the company contain 2.5 ml botulinum toxin, which is dissolved in non-preserved saline solution, it is advisable to inject 1.2 ml per session. To avoid wasting of the material it is always advisable to treat two patients at the same time.
It is possible to treat periorbital wrinkles, perioral wrinkles, a drooping corner of the mouth, and wrinkles in the chin and neck (platysma), as well as forehead wrinkles, with botulinum toxin. The platysma can extend over the thorax as far as beyond the second rib and is above the fascia here. Diagonal neck wrinkles can be treated via 6-12 injection sites. These should be positioned in the shape of an upside-down triangle and 4 U of Botox should be injected at each site, at intervals of 1 cm with the needle at an angle of 45°. This treatment can also be combined with a facelift, but we recommend that botulinum toxin is not be given intraoperatively while the patient is under anesthesia. Botulinum toxin should not be given until the second day after the operation for medicolegal reasons.
More information can be found in Volume I, pp. 244-250.
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