What amount of reconstitution for botulinum toxin type A (BoNTA; BOTOX COSMETIC^®) with saline do you suggest for a patient with hyperhidrosis of the face^*? Typically, I use 1 cc, which requires too many injections. What is your treatment protocol?

^*Not FDA approved for this indication

I use a 1-mL reconstitutution of BoNTA for treating hyperhidrosis of the face^*. This permits a low injection volume with low interstitial pressure—thus, less injection discomfort and less flow of BoNTA away from the injection point into deeper tissues where it would be less likely to come in contact with sweat glands and more likely to cause unwanted muscle relaxation. I am not aware of any evidence that reconstitution volume has any bearing on the lateral diffusion of BoNTA and, anecdotally, I can tell you that the spacing of injections for the treatment of hyperhidrosis does not seem to be influenced by reconstitution volume. I inject using a BD-II 0.3-mL syringe with an attached 31-gauge needle, injecting very superficially (at a depth of about 1 mm) then waiting for a couple of seconds before withdrawing the needle from the skin. This allows interstitial pressure to dissipate and reduce the backflow of BoNTA along the needle track onto the skin.

When treating facial hyperhidrosis with BoNTA, be careful that injections do not interfere with necessary facial muscle function, such as orbicularis oculi, orbicularis oris, and periorbital muscles. The major downside of the use of neurotoxins is collateral paralysis of mimetic and functional muscles.

Response peer reviewed by Mark L. Jewell, MD

Hyperhidrosis requires a larger volume to spread the neurotoxin over a far larger area than is used for the on-label treatment of the glabellar area. There are two factors that must be considered here: that of an increased dilution and the need for greater amount of units of BoNTA. I personally will dilute the 100-unit vial in 4 cc of saline and administer this in the intradermal location for axillae.  

^*Not FDA approved for this indication

Response date: May 2008

I use non–animal-stabilized hyaluronic acid (NASHA; eg, Perlane^®, Juvéderm™ Ultra, Juvéderm™ Ultra Plus) in most of my patients for the correction of tear trough deformity^*. What type of injection would you use, and is a serial puncture technique most appropriate? Would the filler be injected into the trough or medial to the trough for a mild-to-moderate tear trough deformity?

To minimize patient discomfort and the risk of bruising, I inject tear troughs using Juvéderm™ Ultra mixed with 0.15 mL of 2% xylocaine with epinephrine (buffered). This material is loaded into a BD-II 0.3-ml syringes with attached 8-mm, 31-gauge needles by injecting it into the proximal 2/3 of the barrel, then replacing the plunger. (I find that homogenous, cohesive hyaluronic acid gels like Juvéderm™ flow more smoothly through the 31-gauge needle than particulate slurries like Restylane^® and Perlane^®.)

Using the prepared BD-II syringes, I perform serial injections of 0.05-mL aliquots of Juvéderm™ Ultra, directly below the area to be filled and at the greatest possible depth. Moderate finger pressure should be applied immediately (the patient can assist with this) along the treated area for 5 minutes (measured on a clock) to reduce the incidence and severity of bruising. Finally, ultrasound gel (to improve tactile feedback) is applied, and the treated area is carefully palpated and massaged until the product is properly and smoothly distributed.

Response peer reviewed by Mark L. Jewell, MD

I prefer to use Restylane^® or Juvéderm™ Ultra for the tear trough versus other fillers from the hyaluronic acid family. I use a linear thread technique at the level of the periosteum to fill with a small amount of filler—0.2 mL maximum. Some 1% lidocaine with epi 1:100,000 is helpful to diminish local bleeding or bruising. Generally, I try to minimize needle passage to 1 to 2 passes.

^*Not FDA approved for this indication

Response date: May 2008

What would you recommend for a 34-year-old, type IV Asian female with severe pitted acne scarring?

Treatment for this patient depends on the exact nature of the scars, the patient’s skin color, the patient’s propensity for postinflammatory hyperpigmentation and/or keloid scarring, and whether she has ongoing, active skin disease. Assuming that the acne is dormant or has been treated, injection or other types of surface treatments may offer only minimal improvement. Potential treatment options could range from the use of a filler^* (eg, Juvéderm™ Ultra delivered through a BD-II 0.3-mL syringe with 31-gauge needle, prepared as in the answer to the question regarding correction of tear trough deformity with Juvéderm™^*) to the use of energy-based techniques (eg, Fraxel^®, Fraxel^® Re:pair). Referral for consideration of dermabrasion by an expert at this technique would be another possibility if cost is not prohibitive. In some cases, the scars could also be excised or punched out. It’s highly recommended that you be very cautious in aggressively treating this problem.

^*Not FDA approved for this indication

Response peer reviewed by Mark L. Jewell, MD

Response date: May 2008

I treated my patient for glabellar complex, eyebrow lift, and frontalis equally with botulinum toxin type A (BoNTA; BOTOX^® COSMETIC). One side of the eyebrow lift is higher than the other. What is the best treatment action?

The off-label use of dermal fillers to plump the red lip tissue requires a moderately deep placement of the filler. I tend to inject at a depth of about 2 mm in most cases so that the injection is actually made into the superficial orbicularis oris. Ultrasound gel (to improve tactile feedback) is then applied, and the treated area is carefully palpated and massaged until the filler material is properly and smoothly distributed.

Response peer reviewed by Mark L. Jewell, MD

Response date: May 2008