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The Steering Committee
Alastair Carruthers, MD, FRCP(C)
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Ask the Expert

Disclaimer

The information is based on faculty experience and opinion and is intended to provide accurate and authoritative information in regard to the subject matter. Although the information contained herein has been researched and checked for accuracy and completeness, neither Professional Postgraduate Services® nor the author accept any responsibility for errors, omissions, misuse or misinterpretation.


Topics

 

Q.
I have a few patients who developed widening of the nasal root area after injections of botulinum toxin type A (BoNTA; BOTOX COSMETIC®) for improvement of glabellar/frontal lines. The appearance is reminiscent of a wide procerus extending bilaterally at the nasal root giving an awkward look. Is this due to depressor supercilii action or to procerus weakness or strength? What is the pathophysiology and proposed treatment for this outcome?


Response by Sue Ellen Cox, MD
A.

The corrugator supercilii is an abductor (and, to a lesser extent, a depressor) of the medial brow, and treatment of this muscle will result in a spreading of the medial brow area, just as destruction of these muscles in a browlift will result in widening of this area. Depressor supercillii and procerus are primarily depressors of the medial brow, and treatment of these muscles will elevate the medial brow. Treatment in each patient should be individualized according to his/her distinctive anatomy. A lower dose or partial treatment should decrease this effect, but may result in shorter duration of effect.


Response peer reviewed by Steven H. Dayan, MD.


Response date: December 2008.


Q. I’m interested in purchasing a laser for microdermabrasion. Is there a recommendation between either a crystal-less vs a wet dermabrasion (ie silk peel vs the oxygen based-infusion)?

Response by Sue Ellen Cox, MD
A.
We use the Vibraderm instrumentation. This is a system using aluminum-sided paddles that produce exfoliation with controlled vibration. We find this technique provides more even exfoliation with less trauma then suctioning the skin that is found traditionally with crystal type microdermabrasion instrumentation. It is also significantly less messy. All of these techniques provide for varying degrees of exfoliation of the skin. The Silk Peel uses a diamond tip rather than crystals, and a hydrating agent is used to soothe the skin during treatments. Oxygen-based infusion is a marketing strategy–-I have not found any evidence that one machine is more effective. I would suggest bringing the different machines into your office to see which is ergonomically the best fit for the provider.

Response peer reviewed by Steven H. Dayan, MD.

Response date: December 2008.

Q.
I recently treated a 35-year-old female with botulinum toxin type A (BoNTA; BOTOX COSMETIC®) for inferior periorbital lines (15 units per side). Initially, she described a feeling of heaviness and now describes what sounds like binocular diplopia. How can I treat this and, if I can’t, how soon is it expected to resolve on its own?


Response by Sue Ellen Cox, MD
A.
Inferior periorbital lines usually do not respond to BoNTA, as these lines are from skin excess and the upward movement of the malar fat pad with smiling rather than orbicularis muscle contraction. The exception is lines from a hypertrophic orbicularis or medial angular lines after lateral treatment with BoNTA. If these areas are treated, very low doses should be used (1 or 2 units). This treatment should not be done on elderly patients with weaker eyelids, as ectropion could result. This area should be avoided if the patient has “bags” under the eyes because weakening the support of the overlying orbicularis muscle will make the “bags” worse. The diplopia is due to diffusion of the toxin to the inferior oblique muscle. There is no treatment for the diplopia other than time. Duration depends on the dose administered, but could last a few weeks or several months.

Response peer reviewed by Steven H. Dayan, MD.

Response date: December 2008.

Q.
Is it safe to use botulinum toxin type A (BoNTA; BOTOX COSMETIC®) in a patient with an automatic, implantable, cardioverter-defibrillator?


Response by Sue Ellen Cox, MD
A.
Yes.

Response peer reviewed by Steven H. Dayan, MD.

Response date: December 2008.

Q.
My patient has severe hyperhidrosis of the feet; often, her feet slip out of her shoes. What are your recommendations for treatment?


Response by Sue Ellen Cox, MD
A.

The quantity of sweat produced by hyperhydrotic feet can be overwhelming. Conservative treatments are usually ineffective but include iontophoresis, topical aluminum hydrochloride, and oral glycopyrrolate. Botulinum toxin type A (BoNTA) treatments can be very effective, but fairly high doses are needed. Duration of effect seems to be shorter than axillary treatment. Anesthesia for treatment with BoNTA treatment can be challenging, with sedation often useful. Generally, if BoNTA is going to be used to treat the soles of the feet, we use around 200 units per foot.


Response peer reviewed by Steven H. Dayan, MD.


Response date: December 2008.

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