Venturing to the Glabella and Beyond With Botox

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn