ermatologic Therapy Vol 20 2007 407413 rinted in the United State - PDF document

ermatologic Therapy, Vol. 20, 2007, 407Ð413 rinted in the United StatesáAll rights reservedCopyright © Blackwell Publishing, Inc., 2007 DERMATOLOGIC THERAPYlackwell Publishing Incotox in men Androgens are well known to increase skeletalmuscle hypertrophy (3). Androgen receptor anta-gonists suppress excessive induced hypertrophyof skeletal muscle (4). The relationship betweenandrogens and the neuromuscular junction hasbeen studied by the work of Jordan and colleagues5). They noted that androgen receptors are enrichedin the cell nucleus localized at or in the vicinity ofthe neuromuscular junction. It is possible thatandrogens may have an increase in the neuro-oncosmetic use of botulinum toxin alsoshows a difference in dose needed between thesexes. Men having their masseters and temporalistreated for oromandibular dystonia need an addi-tional 25Ð100%, compared to women, accordingto Dr Andrew Blitzer, MD, DDS (personal com-munication, 2007). Each muscle group treated,either cosmetically or for medical reasons, may havetheir own speciÞc dose. Careful study of eachmuscle group in men is necessary to speciÞcallydetail ideal dosages.The glabella is one area in which studies havebeen undertaken speciÞc to men. In a study byarruthers and Carruthers (6), the doseÐresponseelationship was studied between varying doses ofbotulinum toxin. In their study, 80 men wereandomized to receive either 20, 40, 60, or 80 unitsof BOTOX¨ in the glabellar complex. Glabellarlines were evaluated at baseline and 2 and 4eeks post-treatment. The 40-, 60-, and 80-unitdoses were consistently better at improvingglabellar lines than the 20-unit dose. They showeda dose-dependent responsive rate and duration ofeffect as assessed by a trained observer. Importantly,male subjects reported a dose-dependent relation-ship between their ability to frown, improvedglobal assessment, and increased feelings ofattractiveness, self-conÞdence, and satisfaction.There was no increase in adverse events at higherdoses. What was clear from the data is that 20dose; a starting dose of 40 units in the muscles ofthe glabellar complex is recommended. The authorÕscomment in the paper that they regularly startmen at a dose approximately twice that whichthey use in women (60Ð80 U BOTOX¨). FIG. 1shows a male patient treated with 60 units ofBOTOX¨ in the glabellar complex.veral other caveats are important when treatingthe male glab

ella. The corrugator supercilii musclecan vary in its anatomic shape. In many men, ittends to have a rather broad course with the distalÞbers of the muscle inserting into the skin farlaterally. When the male patient is evaluated as tocorrugator size and position, the treating physi-cian must assess these lateral Þbers and inject thetoxin in such a manner that these lateral Þberswill be treated. Failure to place the toxin farenough laterally will result in the male patientbeing able to contract the distal portion of themuscle, producing an unnatural appearance.eatment of the glabellar area results in adelayed effect of lifting brow position. When theglabellar complex is treated, the BTX-A diffusesinto and affects the lower portion of the frontalisedially. Over time, the lateral aspect of thefrontalis muscle, which has been untreated, isable to hypertrophy in response to animation andhas the effect of lifting the lateral brows. Althoughwomen largely appreciate the effect, in men thisbrow lift can appear somewhat unnatural. As will bediscussed further, men look good with horizontalbrows. An unnatural high lateral eyebrow in a malepatient is a visual cue that botulinum treatmenthas been performed. If glabellar BTX-A treatmentperformed too medially, this brow lift canproduce an effectively and excessively archedeyebrow, which is also unnatural in the male. Careshould be taken by the treating physician to con-sider these possibilities and to plan accordingly.any men return after glabellar treatment,feeling that the treatment was ineffective. Showing FIG. 1.A 55-year-old male patient before and after glabellartreatment. Sixty units were used to inactivate the glabellar otox in menthe patient their before and after photographs isusually sufÞcient to document that there wastreatment effect; however, most causes of incom-plete glabellar line treatment are the result oftoo low BTX-A dose used. It is our approach in mento see them back in 2 weeks after their initial treat-ment and to assess their muscle function. In manyuse an additional 10Ð20 U at follow-up.en have to be warned that some long-standingglabellar folds at rest cannot be treated withbotulinum toxin alone. Many folds will requirebotulinum toxin along with a Þller substance (2,8).eported with these injections. FIG. 2 shows amale patient treated with the combination of bothBOTOX¨ and Cosmoderm.The male browtudies o

f iconic beauty (movie stars/classicallook good with an arched brow. Men look hand-some with a horizontal brow. Esthetic physiciansas well as makeup artists and photographersunderstand the differences in the brow. The maleis lower than the female brow and is ineneral not arched. This should be taken into con-sideration when treating men. Arching the browof a male patient may produce a feminine oretty boyÓ appearance.ome men may have brows that are riding in aposition below the supraorbital ridge. In many ofthese patients, prominent horizontal foreheadlines will be noted because these men are usingthe frontalis to elevate their brows in order toallow for a more complete Þeld of vision. Thesepatients can be helped with botulinum toxin.eyebrow to elevate it up and out, and thus returnit to a more elevated position.w-lifting techniques with botulinum toxincan be helpful in men. If one desires to elevate themedial brow, just the central portion of the glabellarcomplex can be treated. The present author oftenperforms one injection into the procerus muscle.elevation of the lateral brow is desired, blinum toxin can be injected into the tail of theeyebrow. Here, vertical Þbers of the orbicularisoculi muscle are relaxed, allowing the lateral browto elevate. Very commonly, if the present authorwishes to elevate the entire brow, both of theseinjections are used.ome men may have excessively peakedeyebrows. This can occur if a too medial injectionof the glabellar complex is performed, or it maybe a congenital effect. One can easily correctthese peaked eyebrows by placing a few units intothe frontalis muscle above the area of the peakedeyebrows. It is always important to remember thatmen usually need more units of botulinum toxinLateral orbital wrinkles (crowÕs feet) are present inmany men. These can be improved with carefuluse of botulinum toxin (9). When treating malepatient who have crowÕs feet, the present authorusually begins with a starting dose of 15 U ofbotulinum toxin in each lateral crowÕs foot (FIG. 3).ome men have a broad expanse of the lateral FIG. 2.A 45-year-old male patient shown in repose withglabellar rhytids shown before and after BOTOX¨ treatmentto the glabella. Cosmoderm¨ was used as an intradermalÞller to improve the resting vertical wrinkle. rbicularis oculi muscle, and they may needdditional units placed in more lateral sites in orderto relax completely t

his portion of the muscula-ture. A simple concept of following the wrinkleswhen treating the crowÕs feet can be helpful whentreating the male patient. Of course, one mustkeep in mind to not go too low on the crowÕs feetarea, which might weaken zygomaticus major andaffect the manÕs ability to smile. Furthermore,chasing crowÕs feet wrinkles too close to the laterallower lid can producing lower eyelid rounding,which can produce an unesthetic appearance.ehead wrinklesany men suffer from prominent horizontalforehead lines. These are formed by excessivecontraction of the frontalis muscle. We can seethese horizontal forehead lines in many youngermen who may have a tendency towards excessiveanimation. Their expressive nature leads to regularcontraction of the frontalis muscle, leading tohypertrophy and wrinkling of the overlying skin.ther individuals have frontalis contraction asthe result of brow ptosis. In order to gain a morecomplete visual Þeld, they contract the frontalis toelevate the brow, allowing full gaze. There areindividuals who can beneÞt with a BTX-A treat-ment; however, older men may beneÞt fromcutting surgery such as a surgical brow lift with orwithout a blepharoplasty.any men have a very broad ßat muscle. Tradi-tional anatomic drawings can indicate a musclewith two muscle bellies, but in many men themidline Þbers overlap considerably. We havethe frontalis as a single muscular sheet thatunderlies the skin of the forehead. On evaluation,patients are asked to elevate their eyebrows. Thisleads to frontalis contraction, and we are able tosee the pattern of horizontal forehead lines. FIG. 4shows a male patient with a good result fromcareful frontalis treatment. A few clinical caveatsare helpful. Some men can have wrinkles thatextend up to the superior portion of the frontalisnear the hairline or where the hairline originated.ailure to treat these superior forehead wrinkleswill lead to patient dissatisfaction and an unnaturalppearance. The lower 2 cm of the frontalis musclecontrols eyebrow position, and it is important tokeep this in mind when treating male patients. Inmany male patients in which we are concernedabout the brow position, the present authorapproaches their treatment as a two-visit session. FIG. 3.A 25-year-old male patient with lateral orbitalhytids. The patient had 15 units of BOTOX¨ injected in theorbicularis oculi muscle. Insets show close-up c

orrection o f the wrinkles. otox in menthe Þrst visit, the upper portion of the frontalismuscle is treated in an attempt to remove rhytids.pon follow-up in 2 weeks, the brow positions areassessed, and careful treatment of the lowertion of the frontalis is undertaken. FIG. 5 showsa patient treated in this fashion. A 22-year-oldman with excessive skin wrinkling of the foreheadis shown in FIG. 6.id and lower faceThe male patient does not seek treatment of thelower face to the same degree as the femalepatient, but men can beneÞt from botulinumtoxin of the mid and lower face. Areas that areamenable to BTX-A treatment include the nasalismuscles, perioral wrinkles, and the depressoranguli oris. Some men suffer from an excessivelyanimated mentalis muscle, which leads to apeach pitÓ chin appearance. These individualscan be treated with botulinum toxin to the mentalis.The author usually uses approximately 10 U in mento treat the mentalis. The platysma muscle can betreated in an attempt to soften platysmal bands. FIG. 4.elaxation of forehead wrinkles with BOTOX¨. FIG. 5.A man with wrinkles present in the lower forehead.ontracting images are shown 2 weeks apart. The patient hadthe upper two-thirds of the forehead treated in the Þrstsession, and the lower forehead was treated 2 weeks later.ote good brow position and relaxed forehead lines. Axillary treatment in menX-A blocks cholinergic nerve activity. It can beused to denervate eccrine sweat glands and thuseduce sweating. Axillary injection of BTX-A ishighly effective in controlling excessive sweatingfound in primary axillary hyperhidrosis (10). Theusual treatment protocol calls for 50 U of botulinumtoxin type A to be injected in each axilla. Theminor starch iodine test can be utilized beforeinjection to document the areas of excessivesweating and also postoperatively to show theeffectiveness of BTX-A for sweat reduction. Theeduction in sweating can last up to 6 months andis greatly appreciated by the patient.Of interest is the work of Heckmann et al. (11) whoshowed improvement of axillary odor by the use ofX-A in normohidrotic studies. They conducteda placebo-controlled, double-blind parallel studyto see if axillary body odor could be improved.Armpit odor is a complex process in whichmicrobes present on the skin and secretion of bio-degradable compounds from eccrine and axillaryapocrine glands are involved. In their study, 5

1healthy volunteers received 50 U of BTX-A in oneaxilla and placebo injections in the other. Odorquality was assessed by both treated subjects asell as by independent raters who were exposedto blinded odor samples derived from the armpitcloth of t-shirts worn by subjects. Samples fromthe BTX-A treated side smelled Òless intenseÓ andÒbetterÓ according to self assessments. Indepen-dent raters also found that the BTX-AÐtreatedsamples has a less intense and better smell. Theseeductions were highly statistically signiÞcant atotulinum toxin treatment of the male urinary tractX-A has been used with increasing popularityamong urologists. Intravesicular applications ofX-A have been shown to be very helpful intreatment of neurogenic overactive bladder andidiopathic detrusor activity (12). BTX-A has beeneffective in causing a decrease in the frequency ofurination and a decrease or absence of incontinence.ost of these treatments last approximately 6months. It is anticipated that BTX-A will beapproved for use in the bladder.Of interest to men is its use in benign prostatichyperplasia. Finding an effectively minimallyinvasive treatment of benign prostatic hyperplasiahas been a challenge. The history of use of BTX-A FIG. 6.Excellent results in a 22-year-old male patient withhyperdynamic lines of the forehead. otox in meninjections in the prostate goes back to 1988, whenDoggweiler injected 30 rat prostates and noticed asigniÞcant reduction in total prostatic volume andeight after 1Ð4 weeks. In 2003, Maria et al. formed a randomized, placebo-controlled studyof 20 men with symptomatic benign prostatichyperplasia. They were randomized to receiveeither saline or 200 units of intraprostatic BTX-A.Clinical improvement was evident by a month. By2 months, 87% of those patients in the treatmentgroup vs. 10% of patients in the control groupeported subjective BPH symptom relief. This was = 0.00001. The degree ofimprovement was remarkable, considering thatmost patients were severe in their reporting ofsymptoms before injections and the results weresustainable up to 12 months after a single injection.urinary incontinence or systemic side effectswere reported over the 20-month follow-up period.ther studies are underway, and we may seethis become a regular treatment option. Currentuestions include what is the optimal dosing regi-en, route of injection, and location of injection.BOTOX¨ is a very

effective treatment for wrinkles.en beneÞt from memetic muscle relaxation andusually require more units than women. The maleglabella is the one cosmetic area that has beenell studied. It is recommended that 40 units beused as the starting dose for the male glabella.ther areas of the male face can be treated andinjections need to keep in mind the greater musclemass in men. Reduction in sweating and decreasingaxillary odor may beneÞt men. BTX-A is beingincreasingly used in the male urogenital tract.eferences1.American Society of Plastic Surgeons Website. The 2000/2005/2007 national plastic surgery. statistics. Arlingtoneights, IL: Published by American Society of Plastic Sur-geons, Downloadable from www.plasticsurgery.org. 2007.2.Flynn TC. Update on botulinum toxin. Semin Cutan Med3.Janssen I, HemsÞeld S, Wang Z, Ross R. Skeletal musclemass and distribution in 468 men and women aged 18Ð88ears. J Appl Physiol 2000: 4.Inoue K, Yamasaki S, Fushiki T, Okada Y, Sugimoto E.Androgen receptor antagonist surpresses exersize-inducedhypertrophy of skeletal muscle. Eur J Appl Physiol Occup: 88Ð91.5.Monks DA, OÕBryant EL, Jordan CL. Androgen receptorimmunoreactivity in skeletal muscle: enrichment atthe neuromuscular junction. J Comp Neurol 2004: : 59Ð6.Carruthers A, Carruthers J. Prospective, double-blind, ran-domized, parallel group, dose-ranging study of botulinumtoxin type A in men with glabellar rhytids. Dermatol Surg: 1297Ð1303.7.BOTOX¨. Cosmetic (botulinum toxin type A) puriÞedneurotoxin complex [package insert]. Irvine, CA: Allergan,Ascher B, Lowe N, Flynn TC, Kane MA, Rey R, Sylvestre G.practical guide to achieving successful outcomes withbotulinum toxin type. Paris: A IMCAS Meeting, 2002.9.Flynn TC. Periocular botulinum toxin. Clin Dermatol 2003:10.Heckmann M, Caballos-Bowman AO, Pleavis G. Botulinumtoxin A for axillary hyperhidrosis (excessive sweating).N Engl J Med 2001: : 488Ð493.11.Heckmann M, KŸtt S, Dittmar S, Hamm H. Making scents:improvement of olfactory proÞle after botulinum toxin atreatment in healthy individuals. Dermatol Surg 2007: 12.Lai HH, Smith CP. Hitting below the belt (bladder): botuli-num toxin treatment of urethral and prostate disorders.urr Urol Rep 2007: ia G, Brisinda G, Massimo I, et al. Relief of voidingdysfunction due to benign prostatic hypertrophy: results ofa randomized, placebo-controlled study of botulinumtoxin. Urology 2003: : 259Ð269.