Balanced botox chemodenervation of the upper face: symmetry in motion.

Cosmetic botulinum toxin type A (Botox, Allergan, Inc., Irvine, CA) has revolutionized minimally invasive treatment of the upper face. Increasingly sophisticated outcomes result in facial symmetry in motion. The face is a three-dimensional moving unit, not an isolated photograph. This is why the advanced injector must hone an astute ability to observe casual microexpressions. Consideration is then given to the patient's age, facial anatomy, facial asymmetry, and dynamic rhytids. The ratio of dosing to agonist and antagonist muscles that allows unopposed action is determined. Nuance in placement and dose combined with adjunct therapy results in natural and appropriate facial emotion and avoids unnatural or bizarre patterns of movement. Asymmetrical scenarios are presented to exemplify this process of analysis and treatment. Many authors have detailed the mechanism of action, history of Botox development, and specific muscle group treatment in the periorbital region. In this discussion, I leave behind rigorous academic analysis and wish to offer my approach, which has evolved through 15 years experience treating the aesthetic patient with Botox. The clinician can read about recommended patterns of injection, and the procedure is quite simple. It is only through skilled observation and understanding of expressive nuance and anatomy that the advanced injector will meet the goal of a natural communicative result with chemodenervation. Experience is accumulated through critical analysis of patient results over time. This discussion first directs attention to why it is important to learn how to look at the face in motion as well as at facial rhytids. A plan is developed for treatment including drug preparation, dosing decisions, precise three-dimensional delivery, and adjunct therapy. Perils may generally be avoided by choosing appropriate dosing and placement. The asymmetrical patient scenario is used to demonstrate nuance in evaluation and treatment.

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