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Understanding the clinical benefits and limitations of botulinum toxin (BTX) therapy is important; these principles must be effectively communicated to every patient in order to ensure more uniform satisfaction. As almost every practitioner of cosmetic enhancement, surgeon and physician alike, uses BTX in his or her clinical practice, it is important to differentiate the quality of one’s BTX therapy from competitors. This chapter will recount how to attain consistently excellent results and to minimize patient discomfort so as to increase patient loyalty and repeat visits. BTX injection is easy to perform but must be undertaken with care and attention for optimal results.

Evaluation of the Potential Patient for Neurotoxin

BTX therapy provides excellent and safe periocular cosmetic enhancement when applied in a deliberate and conscientious method. During the initial consultation, the physician should ask what experiences the patient may have had with BTX in the past and what expectations he or she should hold. Review of the patient’s prior experiences is informative as to what pitfalls the physician can avoid in the current session. For example, if the patient says that the brow position descended excessively with prior usage, the physician should pay particular attention to how to treat the frontalis. Excessive ecchymosis from a previous treatment may reflect careless or inadvertent venipuncture or a patient’s excessive usage of a nonsteroidal anti-inflammatory medication. Counseling a patient during the initial phone encounter to avoid aspirin, herbal therapies, or other blood-thinning medications is important as is avoiding treatment 7–10 days before an important professional or social engagement in case ecchymosis arises and cannot be entirely camouflaged.

It is helpful during the discussion to study the patient’s habits of animation and particular anatomic features before injection is undertaken. During discussion with a patient, the physician may glean clues that can be very informative. For example, the patient may constantly raise or hold the eyebrows skyward to compensate for brow ptosis. Treatment of these frontalis rhytids with BTX will compromise the patient’s ability to lift the brows and be quite devastating for the patient. Having the patient close the eyes tightly and then slowly open them, concentrating all the while on not using the brow muscles, will prove conclusively to the patient that the frontalis is being used to alleviate brow ptosis and therefore should not be injected. In general, it is important to be very conservative in the frontalis muscle for first-time patients who may risk their brows feeling too heavy. Also, the surgeon may observe that the patient constantly frowns during pensive moments. Therefore, the surgeon can advise that therapy of the glabellar musculature may prove beneficial to break this undesirable habit. In fact, treatment of this unintended habitual action over a period of a year may actually break the habit, as the patient unconsciously unlearns this behavior over time. These clinical clues can only be effectively discerned when the patient is unwittingly observed, so the initial cosmetic consultation can be invaluable in many respects for the physician.

Any anatomic differences like brow asymmetry and wrinkle distribution can be pointed out to the patient at this time or during the injection session itself. Unlike many other attempts at correcting asymmetry, BTX can provide a noticeable improvement in asymmetry since it goes to the root of the problem (i.e., muscular pull). The correction of brow asymmetry with a browlift ultimately fails over time as muscular contraction returns the position of the brows back to their native asymmetry.

Prejudices about BTX usage can be unearthed and dispelled during the initial encounter as well. The words “poison” and “toxin” are bandied about as if they were contaminants that would cause ineluctable harm for the body. I usually counter these concerns by explaining that BTX has been perhaps one of the most studied products in the cosmetic industry with the longest history of safety than any product in the cosmetic market, emphasizing that I use only the FDA-cleared neurotoxins, which has been unequivocally safe. I substitute the word “purified protein” for “toxin” when discussing BTX to allay fears and to deliver a gentler message.

Reviewing with the patient the precise aesthetic objectives is very important. As BTX only treats wrinkles in animation, a patient who presents with deeply set static wrinkles would most likely gain very little benefit from therapy. I emphasize that BTX serves two major objectives: to prevent wrinkles from setting in if a consistent regimen is maintained and to help the patient look better during animation so that deep wrinkles do not manifest. For patients who undergo skin therapies like phenol or TCA peels, I stress the importance of BTX in maintaining the durability of that result, like a shirt that is ironed flat (chemical peel) should keep its form if it is never worn (BTX therapy).

Establishing realistic objectives underscores every cosmetic endeavor to minimize patient dissatisfaction and physician headaches thereafter. Finally, for patients who express concern that emotion will be restricted, I explain that BTX limits so-called negative expressions (surprise, anger, worry) but does not limit positive expressions (happiness and joy). Obviously, patients who have careers that require emotive display like actors and screen personalities (who are more dramatic than commercial in their scope) may not be acceptable candidates for botulinum toxin therapy.