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Botulinum toxin (btx) injections are the most popular minimally invasive cosmetic procedure in America with more than 12 million performed in 2011, according to the American Society of Plastic Surgeons (www.plasticsurgery.org). That number was up more than 5% over the previous year and part of that increase may be due to new indications beyond the FDA-approved glabellar lines, forehead furrows and crow’s feet.
“Many of my patients come in for panfacial rejuvenation with neuromodulators and fillers,” says Vic Narurkar, MD, a San Francisco-based dermatologist who specializes in cosmetic dermatology and laser surgery. “I have them move every muscle in the face from brow to neck so I can balance the face. Treatments for crow’s feet are very popular, and I have a number of Asian patients who like the way btx can open up the aperture of the eye. I use it in the chin to relax and elongate the mentalis muscle, around the mouth in the depressor anguli oris to get rid of that downward droop at the corners of the mouth and in the upper cutaneous lip to prevent the gummy smile some women are born with.”
San Francisco-based plastic surgeon Edward P. Miranda, MD, is much more cautious. “Neuromodulators work well for the upper third of the face,” he says, “but I use them sparingly in the lower face. They can work for a few select patients but not for most. I feel like I have a lot of options in my tool box, and a neck or lower facelift is a better choice for most patients.”
Since neurotoxin injections beyond the brow and crow’s feet are not cleared by the FDA, btx manufacturers cannot promote these uses, and that means finding training in these techniques can be difficult.
“These are great tools but only if the doctor really knows what he is doing,” says Barry M. Weintraub, MD, FACS, a Manhattan-based plastic surgeon. “In untrained hands, btx injections can cause serious consequences including distorting the face, at least temporarily.”
Dermatologist and cosmetic surgeon Mitchel Goldman, MD, medical director of Goldman Butterwick Fitzpatrick Groff & Fabi, Cosmetic Laser Dermatology in San Diego, adds, “I’m hoping that one day companies will do studies and get FDA approval for these other areas. Most of us are satisfying these indications in our patients already, but it would be better for us and our patients if we could advertise these applications and vendors could openly provide education in these techniques.”

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