The Ukrainian community of aesthetic medicine doctors has traditionally been a leader in the implementation of innovations, we have been widely using botulinum toxins in the so-called off-label areas for more than 15 years, we have a huge number of publications of various author's methods. The specific mentality of our patients, our doctors, and, to be honest, the wide gaps in our legislation still allow us to feel quite free in the field of innovation.
Nevertheless, I have developed a number of restrictions that I try not to violate. They are not official contraindications - there is an official instruction for the drug. These are my personal stop signs, the signs of which make me refuse to perform this procedure on a patient, since the risk of complications or an extremely unsatisfactory aesthetic result far outweighs the possible advantages. Fortunately, the current field of aesthetic medicine has a sufficient number of alternative ways.
THE FIRST STOP SIGN
The first stop sign is patients with significantly reduced skin elasticity or hyperelastosis. Characteristic markers are the marked effort these patients make to perform regular functions ⎼ for example, to maintain an open gaze. As a result of this "hyper-effort," these patients develop pronounced, intensified wrinkles, often even at the age of 30-40. Professor Belousov has an interesting article "The formula of facial tissues and its application in plastic surgery" published in the journal "Aesthetic Medicine" back in 2006, which is devoted to the assessment of skin condition and makes it possible to assess the prognosis of the effectiveness of lifting in patients of the same age group but with different skin types.
The same rules apply to botulinum toxin. Photo 1 shows a classic case of hyperelastosis: dense, completely inelastic skin, severe impaired blood supply to the dermal layer, a large number of deep wrinkles and furrows. This patient achieved a good aesthetic result with Lip & Eyelid Formula phenolic peeling (Fig. 1).
THE SECOND STOP SIGN
The second marker for refusing a patient to undergo a botulinum toxin procedure is signs of significant impairment of tissue drainage function, that is, when we see that the shutdown of any muscle group will lead to a significant impairment of lymphatic drainage. In the vast majority of cases, this problem is combined with severe somatic pathology, sometimes in a compensated form (for example, stage 23 GB). I am always concerned about the use of ACE inhibitors. According to my observations, most of them cause severe lymphostasis, moreover, the possibility of angioedema with the injection of HA fillers increases significantly. This, in turn, is fraught with complications in therapy, since the bradykinin-kinin system is not amenable to the removal of edema with corticosteroids and antihistamines, unlike edema caused by the kallikrein-kinin system (according to our colleague M. A. Krasnoselsky, it is treated with aspirin or aspirin-cardio (he recommends a preventive preparatory course for patients who initially disturb him with their pronounced pastiness).
Thus, I am always concerned about the patient's general pastiness, a tendency to swelling in the morning, and the question of what medications the patient is taking is mandatory. In general, it should be remembered that after 35 years of age, due to age-related anatomical changes, the role of the drainage function of the lower lateral part of the m. orbicularis oculi increases significantly. Strictly speaking, this portion of the muscle is the only "elevator" upward in the periorbital zone, and it is simply unreasonable to turn it off. I prefer not to go below the line of the outer canthus of the eye when correcting crow's feet. Violation of this rule leads to a high risk of lymphostasis complications and even a higher risk of unfavorable aesthetic results, since the cheek and zygomatic bags, fat bags as a result of such a blockade go down, and the wrinkles of the lower eyelid shift to the root of the nose.
If there is a slight threat of impaired pumping muscle function, we refuse botulinum toxin in favor of HA fillers, threads, phenolic peels, and surgical lifting.
Photos 2 and 3 show the classics of such cases: the first patient ⎼ has severe pastiness, hypertension, and a history of taking ACE inhibitors. Additional "complicating factors" are facial features: the tail of the eyebrow extends to the temporal fossa, so the botulinum toxin is simply unable to raise the eyebrow, blepharochalasis of the upper and lower eyelids guarantees maximum problems in the case of botulinum toxin use in the periorbital zone (Fig. 2).
The second patient is also characterized by pronounced pastiness, hypersthenic structure, herniation of the lower eyelid, narrow forehead and location of the tail of the eyebrow on the temporal fossa, and a heavy middle third. All of this speaks in favor of refusing to use botulinum toxin due to its low effectiveness in this particular case.
THE THIRD STOP SIGN
This includes patients with severe tissue ptosis, hypersthenic body type, and severe tissue excess, especially in combination with reduced skin elasticity. The pinch test remains a classic for detecting such excess skin on the lower eyelid: normally, the skin of the lower eyelid taken in a fold should completely straighten in 23 seconds. The easiest marker of excess skin in the upper third of the face is when creases and wrinkles remain at rest. Severe hypertrophied soft tissues of the lower third will also lead to ineffective correction of the facial oval with botulinum toxin, i.e., the "Nefertiti method" (Philip Levy's method) will not work, which will lead to a failure to meet the patient's expectations.
Photo 4 shows a patient with decreased tissue elasticity and a pronounced excess of soft tissue. An expressive aesthetic result could not have been achieved by using botulinum toxin in any case, perhaps a combination of thread techniques, HA or autofat fillers, and deep peeling would have been more effective. However, the patient really appreciated the set of measures offered to her and preferred plastic surgery. (Fig. 4)
Photo 5 shows a particularly difficult patient. The main problem is not even a pronounced excess of soft tissue, but high-grade hyperelastosis with a serious impairment of the dermis blood supply, complicated by long-term smoking abuse, and therefore, even if you choose plastic surgery, you should limit yourself to the most gentle lifting techniques (subperiosteal, supraperiosteal). since great difficulties in terms of scar healing are expected. (Fig. 5)
Thus, focusing on these markers, I maneuver between different methods of correction and, even if the patient is initially focused on the procedure of botulinum toxin injection, I prefer to convince him of the need to replace the procedure with alternative methods or offer a surgical method of correction.