Complications of botulinum toxin and fillers: A narrative review.

BACKGROUND: Cosmetic surgery and esthetic procedures have become a billion dollar industry owing to the ever-growing demand of the population to stay young. The injectable treatments including fillers and botulinum toxin have become highly popular because of their quick, predictable and lasting results in the management of facial wrinkles and rejuvenation. Although these treatment modalities are relatively safe, they are associated with certain side effects. AIMS: In this review, we will focus on the complications of fillers and botulinum toxin. PATIENTS/METHODS: The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. Only articles available in English were considered for this review. RESULTS: Brow ptosis and asymmetry are common adverse effects of botulinum toxin while the most common adverse effects associated with fillers are the local injection related effects manifesting as erythema, edema, pain, and ecchymosis. CONCLUSION: It is important that the treating physician is well verse with the various fillers and botulinum toxin complications and their management as some of the complications can be severely debilitating.

The effect of eyebrow stenting on the measurement of levator excursion in normal and ptotic eyelids.

Introduction: Levator function is classically estimated by measuring upper eyelid excursion (ULE) with digital brow stenting. The purpose of this study is to compare ULE with and without brow stenting in normal and ptotic eyelids. Methods: In this prospective observational study, normal and ptotic eyelids were recruited. Subjects were photographed with and without digital brow stenting in primary position, downgaze, and upgaze. Measurements were conducted on digital photographs. The primary outcome measure was ULE (distance travelled by the eyelid margin between downgaze and upgaze). Normal and ptosis (MRD1 ≤ 2.5 mm or asymmetry ≥ 1 mm) subgroups were defined. Independent one-way ANOVA and independent samples t-tests were performed. This study was powered to detect a 1 mm difference in the primary outcome measure, assuming SD = 1 mm, with alpha = 0.05 and beta-error = 0.95. Results: Twenty-eight normal eyelids of 22 subjects and 28 ptotic eyes of 18 subjects were included. Stenting significantly (p < 0.01) increased ULE in the overall sample (+0.9 mm) and in controls (+1.2 mm), but not (p > 0.05) in ptotic eyelids (+0.5 mm). Post hoc analysis revealed a beta-error of 0.08 in the latter. Conclusion: ULE was significantly higher with brow stenting in normal eyelids (approximately +1.2 mm) but not in ptotic eyelids, possibly due to increased levator tone secondary to increased effort in the coupled frontalis.

Rejuvenation of the Upper Face and Brow: Neuromodulators and Fillers.

Facial aging involves a combination of volume loss and descent, loss of skin elasticity, dynamic lines due to facial mimetic muscle action, and development of static rhytids. Although surgery remains an option for treatment, minimally invasive aesthetic procedures continue to gain popularity with the use of neuromodulators and soft tissue fillers being the most sought-after procedures. Although these may be used in isolation to treat specific concerns, they are often combined to address multiple facets of aging. Multiple different neuromodulators and fillers are commercially available. Although relatively effective and safe, a thorough understanding of their indications, compositions, and potential adverse effects is paramount. This article will review the available aesthetic products for minimally invasive periorbital rejuvenation with botulinum toxin and injectable fillers. Although it will not focus on other therapies aimed at facial rejuvenation, such as resurfacing techniques or surgical interventions, it is important to note that an individualized treatment plan may combine multiple therapies to optimize patient outcomes and satisfaction.

The Open Browlift.

The eyes and periorbital areas are critical components for the harmonious treatment of the aging face. The authors prefer the open browlift for rejuvenation of the forehead area. The open browlift is the most versatile, effective, and long-lasting method for the treatment of the forehead. The analysis of the forehead area, alternative treatments, variations in incisions, and key components of the surgical procedure are to be reviewed.

Management of the Heavy Brows: Long-Term Surgical Options.

One of the first signs of aging belongs to the upper third of the face. With the aging process, mestizo facial features become more prominent. The thicker skin-soft tissue envelope (S-STE) has a tendency to sag more, hooding of the eyelids tends to be more pronounced, and there is a tendency for eyebrows to droop, specifically the tail of the brows, because of the loss of support. A "tired" or "sad" look implies that the complex eyebrow-upper eyelid is showing one or more of these signs. Different surgical as well as non-surgical techniques have been described to treat this area, every one of them aiming at making the patient look rested and natural. The objective of this study is to describe a technique for endoscopic brow lifting, consisting on minimal incisions, a biplanar dissection, and a different fixation technique designed for helping reshape the brow. This particular surgical technique has shown the advantage of being minimally invasive and effective. Careful analysis of the patient should be made to decide both the technique and the changes desired by the patient and the surgeon. The authors believe the technique described is another option for approaching and fixating the heavy eyebrows in mestizo patients.

Relationship between ocular dominance and brow position in patients with blepharoptosis.

PURPOSE: This study aims to determine if ocular dominance plays a role in predicting compensatory eyebrow elevation in cases of ptosis. METHODS: This retrospective observational cohort study screened all individuals presenting to two tertiary oculoplastics practices with complaints of ptosis for entry. Primary position photographs were obtained. Ocular dominance was assessed via a modified Porta test. Ptosis was defined in bilateral cases as marginal reflex distance of <2.5 mm in both eyes and in unilateral cases as either an MRD1 < 2.5 mm or MRD1 of >1 mm lower on one side. Asymmetry in brow height was defined as a difference of >1 mm. Chi square and t-tests were performed. RESULTS: Sixty-eight patients from the both tertiary practices met inclusion criteria (37 male, 31 female). Concordance between the higher brow and the dominant side was 50.0% (n = 22, p > 0.05). Mean brow height on the dominant side (15.5 mm) was not statistically different than brow height on the non-dominant side (15.3 mm, p > 0.05). The concordance between the higher brow and the lower MRD1 eyelid was not significant (45.5%, n = 20, p > 0.05). The difference in mean brow height between the lower and higher MRD1 eyes was not significantly different (-0.11 mm; p > 0.05). This also held true when restricted to unilateral cases (0.28; p > 0.05). CONCLUSIONS: Although asymmetric brow elevation can be noted in patients with ptosis, ocular dominance does not appear to be concordant with this asymmetry. Additionally, brow height does not appear to be concordant with MRD1 in cases of ptosis.

Reanimation of the brow and eye in facial paralysis: Review of the literature and personal algorithmic approach.

Facial palsy patients suffer an array of problems ranging from functional to psychological issues. With regard to the eye, lacrimation, lagophthalmos and the inability to spontaneously blink are the main symptoms and if left untreated can compromise the cornea and vision. There are a multitude of treatment modalities available and the surgeon has the challenging prospect of choosing the correct intervention to yield the best outcome for a patient. The accurate assessment of the eye in facial paralysis is described and by approaching the brow and the eye separately the treatment options and indications are discussed having been broken down into static and dynamic modalities. Based on our unit's experience of more than 35 years and 1000 cases of facial palsy, we have developed a detailed approach to help manage these patients optimally. The aim of this article is to provide the reader with a systematic algorithm that can be used when consulting a patient with eye problems associated with facial palsy.

Madarosis, milphosis, eyelash trichomegaly, and dermatochalasis.

Eyebrows, eyelashes, and eyelids are cosmetically and functionally important periocular landmarks that offer insights into a patient's emotional state. Several pathologies exist with respect to the eyebrows, eyelashes, and eyelids. Madarosis refers to loss of the eyebrows or eyelashes; milphosis refers specifically to eyelash loss. Excess growth of eyelash hair is termed trichomegaly. Excess skin in the upper or lower eyelids is called dermatochalasis. Pathology of these important structures can be reflective of important local and systemic disease processes.

Does upper blepharoplasty affect frontalis tonicity?

BACKGROUND: Frontalis hypertonicity has long been implicated in patients with significant dermatochalasia or blepharoptosis, as evidenced by eyebrow changes that occur after the resection of redundant skin or after blepharoptosis operation. However, whether upper blepharoplasty affects the forehead muscle has not been reported. Thus, this study investigated electrophysiology of the frontalis muscle and eyebrow morphology in a population of patients undergoing double-eyelid blepharoplasty. METHOD: Patients wishing to undergo upper blepharoplasty were recruited for this prospective study between June 2011 and February 2012. The subjects were excluded for complaints of visual obstruction, trauma history, and for any underlying medical condition that would affect eyebrow height or electromyogram (EMG) findings. Eyebrow morphology was ascertained in a standardized photogrammetric evaluation, and the frontalis muscle activity was recorded with needle EMG. These assessments were carried out at preoperation and at 2 weeks, 3 months, and 6 months. Root-mean-square (RMS) indices of various facial expressions were used to normalize the frontalis activity values across individuals. RESULTS: Thirteen patients with a mean age of 55.5 years were recruited. No statistical significance was observed for eyebrow heights at various assessment points. However, EMG recordings have demonstrated a gradual decrease in the proportional RMS index of the frontalis muscle activity. This difference was statistically significant between preoperation and 6 months postoperation (p < 0.05). CONCLUSION: Upper blepharoplasty was associated with gradual decreases in the frontalis muscle activity. A longer follow-up study is needed to evaluate whether this decreased tonicity results in morphologic changes such as decreased forehead wrinkles and depressed eyebrows. This research indicates that upper blepharoplasty has the potential to interfere with those human-computer interaction designs with facial EMG readings as an input.

Unilateral generalized keratosis pilaris following pregnancy.

Keratosis pilaris (KP) is a common inherited disorder characterized by small folliculocentric keratotic papules that may have surrounding erythema, which gives the skin a stippled appearance resembling gooseflesh. The extensor surfaces of the upper arms, thighs, and buttocks commonly are affected, but a generalized presentation may occur. We report the case of a 29-year-old woman with unilateral generalized KP in the second month of her second pregnancy. Both a genetic mutation and pregnancy-induced hormonal changes played possible roles in the development and progress of unilateral generalized KP in this patient.

Ulerythema ophryogenes: updates and insights.

Ulerythema ophryogenes is a rare cutaneous atrophic disorder that occasionally is associated with Noonan syndrome, de Lange syndrome, Rubinstein-Taybi syndrome, and cardiofaciocutaneous (CFC) syndrome. Often presenting in pediatric patients, the pathogenesis of ulerythema ophryogenes remains unclear, though several genetic causes have been suggested. Treatment recommendations remain anecdotal, but clearance has been noted as the patient ages. Although topical agents have been the mainstay of therapy, recent advancement in laser intervention for treatment of ulerythema ophryogenes is promising.

Keratosis pilaris and prevalence of acne vulgaris: a cross-sectional study.

BACKGROUND: Acne vulgaris has an important genetic predisposition, as well as keratosis pilaris. Clinical observations suggest that patients with keratosis pilaris have less frequent or less severe acne breakouts; however, we found no studies on this regard OBJECTIVE: To determine if the presence of keratosis pilaris is associated with lower prevalence and severity of acne. METHODS: A cross-sectional study was conducted with dermatology outpatients aged between 14 and 35 years. We evaluated history and clinical grade of acne, demographic variables, history of atopy, smoking, and use of hormonal contraceptives. Two groups were defined by the presence or absence of moderate to severe keratosis pilaris on the arms and were compared by bivariate analysis and by conditional multiple logistic regression. RESULTS: We included 158 patients (66% women), with a median age of 23 ± 11 years. Twenty-six percent of them had keratosis pilaris, which was associated with a history of atopy (odds ratio [OR]=2.80 [1.36 to 5.75]; p<0.01). Acne was present in 66% of subjects, and was related to family history of acne (OR=5.75 [2.47 to 13.37]; p<0.01). In bivariate and multivariate analysis, the group with keratosis pilaris had a less frequent history of acne (OR=0.32 [0.14 to 0.70]; p<0.01). CONCLUSION: The presence of moderate to severe keratosis pilaris on the arms was associated with lower prevalence of acne vulgaris and lower severity of facial lesions in adolescents and young adults.

Keratosis pilaris and prevalence of acne vulgaris: a cross-sectional study

BACKGROUND: Acne vulgaris has an important genetic predisposition, as well as keratosis pilaris. Clinical observations suggest that patients with keratosis pilaris have less frequent or less severe acne breakouts; however, we found no studies on this regard OBJECTIVE: To determine if the presence of keratosis pilaris is associated with lower prevalence and severity of acne. METHODS: A cross-sectional study was conducted with dermatology outpatients aged between 14 and 35 years. We evaluated history and clinical grade of acne, demographic variables, history of atopy, smoking, and use of hormonal contraceptives. Two groups were defined by the presence or absence of moderate to severe keratosis pilaris on the arms and were compared by bivariate analysis and by conditional multiple logistic regression. RESULTS: We included 158 patients (66% women), with a median age of 23±11 years. Twenty-six percent of them had keratosis pilaris, which was associated with a history of atopy (odds ratio [OR]=2.80 [1.36 to 5.75]; p<0.01). Acne was present in 66% of subjects, and was related to family history of acne (OR=5.75 [2.47 to 13.37]; p<0.01). In bivariate and multivariate analysis, the group with keratosis pilaris had a less frequent history of acne (OR=0.32 [0.14 to 0.70]; p<0.01). CONCLUSION: The presence of moderate to severe keratosis pilaris on the arms was associated with lower prevalence of acne vulgaris and lower severity of facial lesions in adolescents and young adults. .

Detection and perceptual impact of side-to-side facial movement asymmetry.

IMPORTANCE: In this study, we examined whether specific facial movements have different time-delay detection thresholds, and to what extent such side-to-side facial movement asymmetry affects subjective ratings of movement naturalness. Ratings of dynamic asymmetry in experimentally manipulated video recordings demonstrate that there are different side-to-side time-delay thresholds for distinct regions of the face, with a strong inverse correlation between naturalness rating and the length-of-time delay. These findings will be helpful for counseling patients with unilateral facial paralysis and guide the design of neural interfaces for facial reanimation. OBJECTIVE: To determine the detection threshold of side-to-side facial movement timing asymmetry and measure its effect on perceived movement naturalness. DESIGN, SETTING, AND PARTICIPANTS: Videos of 5 symmetrical facial movements (eye blink, rapid eyebrow raising, slow eyebrow raising, smiling, and lip depression) were edited to introduce 6 levels of side-to-side timing asymmetry, ranging from 33 to 267 milliseconds. Participants (N = 58) viewed video clips through an online survey service, indicating whether they noticed side-to-side asymmetry and judging movement naturalness on a 5-point scale. RESULTS: There was a significant difference among facial movements in asymmetry detection threshold. There was a strong correlation between naturalness ratings and amount of delay across movements (R = 0.823), with greater asymmetry being judged as progressively less natural. Blink was judged as less natural at 33, 67, 100, and 133 milliseconds of side-to-side delay compared with all other movements (P < .005). CONCLUSIONS AND RELEVANCE: Side-to-side asymmetry in blink timing is detected sooner and viewed as less natural compared with asymmetry of the eyebrow and lips. At 100 milliseconds of delay, nearly all movements are detected as asymmetric, although blink is judged as the least natural. These findings will help set timing goals for facial pacing technologies treating unilateral paralysis. LEVEL OF EVIDENCE: NA.

Long-pulsed 1064-nm Nd:YAG laser significantly improves keratosis pilaris: a randomized, evaluator-blind study.

BACKGROUND: Keratosis pilaris (KP) is a very common disorder; yet, very few treatment options are available. OBJECTIVES: To evaluate the efficacy of long-pulsed 1064-nm Nd:YAG laser for the treatment of KP. MATERIALS AND METHODS: Eighteen patients with untreated KP on the upper outer arms were enrolled in a randomized clinical trial. One arm was treated with long-pulsed 1064-nm Nd:YAG laser at 30 msec pulse width and fluence of 34 J/cm(2), while the contralateral arm served as control. Patients received three consecutive treatments at 4-week intervals. Three blinded dermatologists assessed digital photographs using a quartile grading system to separately rate global improvement, erythema and the number of keratotic papules. RESULTS: Seventeen patients completed the study. There were statistically significant improvements in global assessment, erythema and the number of keratotic papules at 4 weeks after the last treatment (p < 0.05). All patients also stated that their lesions improved and were satisfied with the laser treatment. CONCLUSION: Long-pulsed 1064-nm Nd:YAG laser has been shown to improve KP in Thai patients compared with control after three treatment sessions.

Asymmetric eyebrow elevation and its association with ocular dominance.

PURPOSE: To examine the relation between asymmetric eyebrow elevation and ocular dominance. METHODS: A retrospective cohort study was performed in patients who underwent bilateral upper eyelid blepharoplasty from July 2007 to May 2009. Patients with pre- and postoperative involuntary asymmetric eyebrow elevation were selected from a surgical log database for inclusion in this study. Brow asymmetry was determined by examination of preoperative and postoperative digital photographs and was defined as a measured eyebrow-height difference in conjunction with the asymmetric recruitment of the frontalis muscle. Ocular dominance was determined by using a modified Porta test. Statistical analysis was performed by using the Fisher Exact test. RESULTS: Forty-seven patients met inclusion criteria. Sixty-six percent (31 of 47) involuntarily, asymmetrically elevated the right eyebrow, and 34% (16 of 47), the left. Of the 31 patients with right eyebrow elevation, 87% (27 of 31) were right-eye dominant, and 13% (4 of 31) were left-eye dominant (p < 0.001). Among patients with asymmetric left eyebrow elevation, 62.5% (10 of 16) were left-eye dominant, whereas only 37.5% (6 of 16) patients were right-eye dominant (p < 0.001). CONCLUSION: We report for the first time that involuntary asymmetric eyebrow elevation and ocular dominance are significantly associated. The assessment of ocular dominance should be included in the pre- and postoperative evaluation of patients with asymmetric brow elevation undergoing blepharoplasty. This asymmetry and its etiology must be recognized, so that an attempt to create symmetry does not result in the overcorrection of the contralateral eyelid that may lead to complications such as lagophthalmos and exposure keratopathy.