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La paralysie faciale peut être source de séquelles esthétiques et fonctionnelles à types de spasmes et de syncinésies. L'injection de toxine botulique constitue un des traitements clefs de ces séquelles. Son utilisation est largement rapportée dans la littérature pour de nombreux muscles de la face mais peu pour le muscle buccinateur. Pourtant, son hyperactivité peut être invalidante, générant des troubles de la mastication et du sourire notamment. Le but de cette étude prospective est de rapporter les effets des injections de toxine botulique grâce à un questionnaire d'évaluation spécifique au muscle buccinateur. L'étude a été menée sur 13 patients. Les paralysies faciales étaient d'origines diverses. Le questionnaire comportait 10 questions évaluant chacune une mimique faciale impliquant le muscle buccinateur. L'échelle de notation allait de −10 (détérioration majeure) à 10 (amélioration majeure) pour chaque question. L'évaluation était effectuée à 1 et 4 mois de l'injection. Nous avons retrouvé une amélioration pour l'ensemble des mimiques et gestes évalués (0 à 7,38 à 1 mois et 0,15 à 6,62 à 4 mois). Cette amélioration est plus importante à 1 mois qu'à 4 mois. Peu d'effets secondaires ont été rapportés. Les injections de toxine botulique constituent une solution thérapeutique efficace, sûre pour le traitement des séquelles de paralysie faciale du muscle buccinateur au travers d'un questionnaire spécifique nouveau. Par la suite, il serait intéressant de réaliser une évaluation sur une population plus importante et comparative avec d'autres scores reconnus dans la paralysie faciale. Facial paralysis can cause aesthetic and functional sequelae such as spasms and synkinesis. Botulinum toxin injection is one of the key treatments for these sequelae. Its use is widely reported in the literature for many muscles of the face but little for the buccinator muscle. However, its hyperactivity can be disabling, generating chewing and smile disorders in particular. The aim of this prospective study is to report the effects of botulinum toxin using a questionnaire specifically for the buccinator muscle. The study was conducted on 13 patients. The facial paralysis was of various origins. The questionnaire consisted of 10 questions each assessing a facial mimic involving the buccinator muscle. The rating scale ranged from -10 (major deterioration) to 10 (major improvement) for each question. The evaluation was done at 1 and 4 months after the injection. We found an improvement for all the mimics and gestures evaluated (0 to 7.38 at 1 month and 0.15 to 6.62 at 4 months). This improvement was greater at 1 month than at 4 months. Few side effects were reported. Botulinum toxin injections are an effective, safe therapeutic solution for the treatment of the facial paralysis sequelae of the buccinator muscle through a new specific questionnaire. Subsequently, it would be interesting to carry out an evaluation on a larger population and to compare it with other recognized scores in facial paralysis. [ABSTRACT FROM AUTHOR]

Improving the survival rate of fat grafts is yet a difficult problem in the field of autologous fat transplantation. Prevailing methods such as making nanofat and SVF are time-consuming. Hence, the role of additives application in the improvement of fat graft survival during fat transplantation was considered and preliminarily evaluated in a rabbit animal model. A rabbit animal model was established where rabbit ears were injected with a mixture of 1.5 mL of adipose tissue and 1 mL of saline (group A), 1.5 mL of adipose tissue and 1 mL of botulinum toxin A (BoNTA) (group B), 1.5 mL of adipose tissue and 1 mL of prostaglandin E2 (group C), 1.5 mL of adipose tissue and 1 mL of PDRN (group D) respectively. Then, the extents of neovascularization and inflammation were evaluated on the 7th, 14th, 28th, 42nd, 56th and 70th day after injection by ELISA assays and H&E and immunofluorescence staining. The results showed that pre-treatment with BoNTA, prostaglandin E2 and PDRN improved graft volume and weight. The H&E and immunofluorescence staining revealed that BoNTA, prostaglandin E2 and PDRN improved the graft angiogenesis. Simultaneously, TNF-α expression level detected by ELISA was the lowest in the PDRN group. Henceforth, the present preliminary study suggests that pre-transplantation treatment with BoNTA, prostaglandin E2 and PDRN can improve the fat graft angiogenesis and graft integrity, whereby the effect of adding PDRN may be significant. [ABSTRACT FROM AUTHOR]

In this study we have based our research on botulinium toxin injection via targeted neuromuscular end plate zones, specifically in muscles with diffuse distribution of the latter. The muscular surface anatomical variety was also taken into consideration with thorough pre-injection examination of every subject. With consideration of the facial muscles anatomical variation and neuromuscular bundle distribution, we have applied the method of retrograde botulinium toxin injection on a series of 10 patients on the right side of the face with the left side as a control side, it was injected in a regular perpendicular manner in order to conclude the efficacy of targeted motor end zone injection. Using an auto-injecting syringe, we have delivered 6 Allergan units per zone (frontalis, glabellar lines of corrugator supercilii and orbicularis oculi crow's feet). On control day 8 we have noticed a more prominent effect mainly on the level of the orbicularis oculi muscle and the corrugator supercilii muscle on 9 out of 10 patients. Nine patients out of 10 needed the delivery of an additional 6 Allergan units per zone on the control side's glabellar lines and crow's feet rhytids. Where 1 out of 10 patients needed the reinjection of the control side on the glabellar lines zone. The musculature of the face varies when it comes to neuromuscular plate distribution. Muscles with scattered distribution patterns show an optimal response to botulinum toxin injections when delivered in a retrograde manner. This has allowed us to achieve of optimal results while minimizing injection sites and hence pain, the use of lower dosage and hence treatment cost, as well as lowering the unwanted product dissemination to the neighboring mimic muscles. [ABSTRACT FROM AUTHOR]

Les séquelles de paralysie faciale ont un impact psycho-social intense qui impose une prise en charge optimale au long court. Les challenges chirurgicaux sont nombreux et les moyens thérapeutiques sont à choix multiple. Nous proposons une analyse de ces traitements par le prisme de leurs écueils et de leurs limites. Les complications des principales interventions chirurgicales sont décrites ainsi que le détail des reprises chirurgicales nécessaires pour y faire face ou pour corriger rapidement les malfaçons. Par ailleurs les limites de résultat sont détaillées avec des propositions de retouches pour les améliorer. Enfin nous développons les nécessaires traitements itératifs ou les nouvelles propositions thérapeutiques indispensables à l'accompagnement au long court de ces patients dont les séquelles de paralysie faciale évoluent avec le temps et le vieillissement. La chirurgie des paralysies faciales n'est pas univoque. Elle nécessite humilité, patience et ténacité pour accompagner le patient tout au long de sa vie. Facial paralysis sequelae have an intense psycho-social impact which imposes an optimal care in the long run. The surgical challenges are numerous, and the therapeutic weapons are multiple. We propose an analysis of these treatments by the prism of their pitfalls and their limits. The complications of the main surgical procedures are described as well as the details of the rework necessary to cope with them or to quickly correct the defects. Moreover, the result limits are detailed with suggestions to improve them. Finally, we develop the necessary iterative treatments or new therapeutic proposals that are essential for the long-term care of these patients whose sequelae of facial paralysis evolve with time and aging. The surgery of facial paralysis is not unequivocal. It requires humility, patience and tenacity to support the patient throughout his life. [ABSTRACT FROM AUTHOR]

Les injections de toxine botulique en médecine esthétique sont les produits les plus utilisés, devant l'acide hyaluronique, et la médecine esthétique est en augmentation constante, y compris dans la population masculine. L'objectif de cette mise au point était de montrer les spécificités décrites dans la littérature concernant les injections de toxine botulique chez l'homme. Une recherche systématique de la littérature a été réalisée grâce au moteur de recherche Pubmed. Les données ont ensuite été collectées afin de connaître les spécificités des injections de toxine botulique chez l'homme en fonction de la morphologie du visage masculin et des désirs de ces patients. Les études réalisées montrent qu'il est nécessaire d'injecter des doses plus importantes chez l'homme que chez la femme pour obtenir un résultat satisfaisant, en raison d'une masse musculaire plus importante. Cette mise au point donne le nombre de points à réaliser par zone d'injection, ainsi que le nombre de points à effectuer, en comparaison à la population féminine. Les injections de toxine botulique à visée esthétique chez l'homme diffèrent par rapport à la femme. La prise en compte de ces particularités est indispensable à la satisfaction des patients. Botulinum toxin injections in aesthetic medicine are the most widely used products, ahead of hyaluronic acid, and aesthetic medicine is constantly increasing, including in the male population. The objective of this development was to show the specificities described in the literature concerning botulinum toxin injections in men. A systematic literature search was carried out using the Pubmed search engine. Data were then collected to determine the specificities of botulinum toxin injections in men according to the morphology of the male face and the wishes of these patients. The studies conducted show that it is necessary to inject higher doses in men than in women to obtain a satisfactory result, due to a higher muscle mass. This adjustment gives the number of points to be performed per injection site, as well as the number of points to be performed, compared to the female population. Botulinum toxin injections for aesthetic purposes in men are different from those in women. Taking these particularities into account is essential to patient satisfaction. [ABSTRACT FROM AUTHOR]

Résumé Le but de cet article est de présenter les différentes techniques de rajeunissement du front ainsi que leurs indications. Le lissage cutané, les injections de fillers ou de toxine botulique, le lifting frontal par voie endoscopique, par voie transpalpébrale ou le lifting classique par incision bicoronale doivent être parfaitement connus des chirurgiens plasticiens dans le cadre du traitement global du vieillissement du visage. Seule la chirurgie permet d’obtenir des résultats pérennes et nous devons la proposer dès que les stigmates du vieillissement sont installés. Summary The goal of this article is to provide a systemic approach to forehead rejuvenation. Fillers, botulinic toxin injections, transpalpebral, endoscopic or bicoronal brow lift must be usual techniques for every plastic surgeon in overall facial rejuvenation. Achieving a long lasting and aesthetically pleasing forehead is possible only with surgical techniques when aging is obvious. [ABSTRACT FROM AUTHOR]

Résumé La paralysie faciale (PF) de l’enfant est congénitale ou acquise. Lorsqu’elle est présente à la naissance (congénitale), elle est d’origine traumatique dans la plupart des cas, ou plus rarement, développementale. La PF acquise doit faire rechercher une étiologie pour guider le pronostic et le traitement, même si aucune cause n’est identifiée dans la plupart des cas. Au stade aigu, le traitement de la PF idiopathique repose sur la corticothérapie orale le plus rapidement possible et la protection cornéenne. Au stade des séquelles, comme chez l’adulte, le traitement est global en prenant en compte l’équilibre dynamique des deux côtés du visage. La réanimation dynamique doit prévaloir principalement à l’étage inférieur. Notre choix technique se porte sur la myoplastie d’allongement du temporal (MAT) qui offre la possibilité d’une réanimation du sourire fiable et reproductible. Toute réanimation dynamique par MAT ou lambeau musculaire libre doit être suivie d’une rééducation spécifique prolongée qui accompagne le patient d’un sourire mandibulaire à un sourire spontané grâce à la plasticité cérébrale. Par ailleurs, la toxine botulique, très bien tolérée et peu invasive, est une aide précieuse chez l’enfant capable d’en supporter les injections. Summary Facial palsy (FP) in children is congenital or acquired. When present at birth (congenital), etiologies are mostly traumatic and rarely developmental. Acquired FP needs investigation. Research on the etiology helps to determine prognostic and treatment. At most times, no specific cause is found. Treatment of idiopathic FP consists of early oral corticosteroid therapy and ocular protection. Treating the sequelae is essential and the physician has to consider the dynamic balance of both sides of the face. Dynamic rehabilitation should mainly concern the inferior facial third. We recommend the lengthening temporalis myoplasty (LTM). This relevant technique ensures replicable and reliable results with a harmonious smile. Facial dynamic rehabilitation after surgical procedure (muscle tranfer or free muscle flap) must be directed toward control of voluntary movement, to move from a mandibular smile to a spontaneous and voluntary smile, thanks to brain plasticity. Furthermore, botulinum toxin is well tolerated and remains a great tool to treat a child who can support injections. [ABSTRACT FROM AUTHOR]

Summary Study objectives Botulinum toxin is a key therapeutic tool in the comprehensive treatment of peripheral facial paralysis. It fights spasms, synkinesis and overactivity of the different skin muscles responsible of facial expressions. Even though injection techniques as well as target muscles have been well identified, doses used remain quite imprecise and often not detailed muscle by muscle, further more dosage progression has not been monitored over time. Our retrospective study is the first one to refine the repartition of botulinum toxin doses on each of the relevant skin muscles and assess dosage kinetics. Patients and methods Thirty patients were included since 2008 with a mean follow-up of 2.3 years. Each patient had at least 3 injections, with a delay of 4 to 6 months between each injection. Results Mean doses are indicated for each muscle injected on the paralyzed and healthy sides. Dose kinetics suggests an initial dosage increase after the first injection followed by a decrease over time. No treatment resistance was observed. Conclusion Our study represents a didactic help in using botulinum toxin for sequelae of peripheral facial paralysis by providing more details on the effective mean doses for each muscle and their progression over time. [ABSTRACT FROM AUTHOR]

Résumé L’injection de toxine botulique au niveau de la région axillaire est une procédure visant à traiter de manière temporaire l’hyperhidrose axillaire. Cette technique décrite en 1996 par Bushara et al. a fait la preuve de son efficacité et de sa tolérance satisfaisante. L’objet de cet article est de faire le point sur le traitement de l’hyperhidrose axillaire par injection de toxine botulique de type A, et de discuter la place des autres modalités de traitement de cette affection socialement invalidante. Summary Injection of type A botulinum toxin in the armpits is a temporary treatment for axillary hyperhidrosis. This technique described in 1996 by Bushara et al., is known to be efficient and safe. The purpose of this article was to review the data concerning the treatment of axillary hyperhidrosis with botulinum toxin type A, and discuss the other treatment modalities for this socially disabling entity. [ABSTRACT FROM AUTHOR]

Résumé Le traitement médical des séquelles de la paralysie faciale est une part essentielle de la prise en charge globale de cette pathologie. L’utilisation de la toxine botulique de manière courante a révolutionné les résultats obtenus en améliorant grandement la symétrie faciale. La toxine peut être utilisée soit du côté sain du visage en traitant l’hyperactivité compensatrice du côté non paralysé de la face, soit du côté paralysé (dans les formes spastiques) afin de traiter les co-contractions et les spasmes du côté du visage atteint. Ce traitement devra bien entendu être complété par le reste de la thérapeutique à savoir la rééducation et le traitement chirurgical. Summary Medical treatment of facial paralysis sequel is an essential part of the overall management of this pathology. The use of botulinum toxin has revolutionized results in greatly improving facial symmetry. The toxin can be used either the healthy side of the face by treating the compensatory hyperactivity of non-paralyzed side of the face or the paralyzed side (in the spastic forms) to treat synkinesis and spasms of the face on the pathologic side. This treatment course will be complemented by the rest of the therapeutic, i.e. rehabilitation and surgical treatment. [ABSTRACT FROM AUTHOR]

Résumé L’utilisation de fillers, soit comme camouflage après une rhinoplastie chirurgicale, soit comme technique de rhinoplastie médicale, est devenu un apport intéressant permettant d’éviter ou de retarder une échéance chirurgicale toujours redoutée par le patient. Le geste peut paraître simple mais les auteurs insistent sur la nécessité d’une technique rigoureuse, car si les complications sont rares, elles n’en demeurent pas moins graves voire dramatiques. Au travers de leur expérience de plus de 7 ans, les auteurs n’ont retenu que deux substances résorbables type acide hyaluronique ou hydroxyapatite de calcium, produits reconnus par l’ANSM. Les microcanules (27 G) sont préférées aux aiguilles, ainsi que les techniques d’injection par de multiples tunnels avec des petits bolus fragmentés. Il faut éviter une injection isolée en grande quantité, source de blanchiment et de risques plus importants pour la peau. L’hydroxyapatite est préféré pour le dorsum et l’acide hyaluronique pour la pointe. Les auteurs rapportent également les principales complications et leurs traitements. La meilleure thérapeutique reste néanmoins dans leur prévention en grande partie due à l’application d’une technique rigoureuse. Summary The use of fillers for camouflage after surgical rhinoplasty or during medical rhinoplasty process represent an attractive technique which allows to avoid or to delay surgical time often dreaded by the patients. This technique apparently quite simple, must be applied carefully in order to avoid possible complications that can sometimes be very serious. Through their seven years of experience, the authors have selected absorbable type of products: hyaluronic acid or calcium hydroxylapatite, both approved by ANSM. Preference is given to microcannulas (27G) over needles and injection techniques through multiple tunnels fitted with small fragmented boluses. Due to possible Tyndall effect and skin necrosis risk, a one-shot injection with a lot of product should be avoided. Calcium hydroxyapaptite is preferred for the dorsum area while hyaluronic acid is recommended for the tip. The authors also relate the major encountered complications and describe the appropriated treatments. Nevertheless the strict application of the described technique represents the best way to prevent adverse complications. [ABSTRACT FROM AUTHOR]

Summary: Introduction: Hypertrophy of the masticatory muscles most commonly affects the masseter. Less common cases of isolated or associated temporalis hypertrophy are also reported. Parafunctional habits, and more precisely bruxism, can favor the onset of the hypertrophy. This condition is generally idiopathic and can require both medical and/or surgical management. Observation: A 29-year-old patient was referred to our department for an asymmetric swelling of the masticatory muscles. Physical examination revealed a bilateral hypertrophy of the masticatory muscles, predominantly affecting the right temporalis and the left masseter. Major bruxism was assessed by premature dental wearing. The additional examinations confirmed the isolated muscle hypertrophy. Benign asymmetric hypertrophy of the masticatory muscles promoted by bruxism was diagnosed. Treatment with injections of type A botulinum toxin was conducted in association with a splint and relaxation. Its effectiveness has been observed at six months. Discussion: Few cases of unilateral or bilateral temporalis hypertrophy have been reported, added to the more common isolated masseter muscles hypertrophy. The diagnosis requires to rule out secondary hypertrophies and tumors using Magnetic Resonance Imaging. The condition is thought to be favoured by parafunctional habits such as bruxism. The conservative treatment consists in reducing the volume of the masticatory muscles using intramuscular injections of type A botulinum toxin. Other potential conservative treatments are wearing splints and muscle relaxant drugs. Surgical procedures aiming to reduce the muscle volume and/or the bone volume (mandibular gonioplasty) can be proposed. [ABSTRACT FROM AUTHOR]

Summary: Introduction: After facial paralysis recovery, it is common to note a co-contraction between depressor anguli oris (DAO) muscle and zygomatic muscles. This DAO co-contraction will “obstruct” the patient''s smile. The purpose of this technical note is to show how to find the DAO sign and how to free up the smile. Technical: This co-contraction between the zygomatic muscles and DAO research is placing a finger on marionette line, asking the patient to smile: we perceive a rope under the skin corresponding to the abnormal contraction and powerful DAO. A diagnostic test with lidocaine injection into the DAO can be performed to confirm the diagnosis. The treatment of pathological DAO''s contraction can be by injection of botulinum toxin in the DAO, or by surgical myectomy. In all cases, a speech therapy complete the treatment. Conclusion: The DAO sign is a semiological entity easy to find. His treatment releases smile without negative effect on the facial expression as the DAO is especially useful in the expression of disgust. [Copyright &y& Elsevier]

Summary: Better new understanding of midfacial ageing and new techniques such as botulinum toxin and hyaluronic acid injections have widely changed the approach of the treatment. After reviewing the different available products, the author preconizes for each an overview with indications, limits and possible complications. The author highlights the benefit of these techniques for lower lid and tear trough treatments. Besides, the author suggests associating these techniques for natural and long lasting results. [Copyright &y& Elsevier]

Summary: The actual gold standard of Botulin A toxin (BoTx A) batches qualification is the mouse lethality assay. With this assay it is nevertheless impossible to set a therapeutic value unit. Aims: The goal of this research was to study the effects of BoTx A increasing concentrations on glutamatergic rat neurons. Experimental procedure: We studied the glutamate release with increasing concentrations of BoTx A. We also studied the BoTx A target cleavage with a western blot technique. Results: Our results proved that it is possible to establish a dose-response – like curve of BoTx A effects on glutamate release. Moreover the cleavage of the target protein was visible for the same toxin concentrations that inhibited the glutamate release. Conclusion: This technique could be the first step toward a new way of setting a better pharmaceutical profile for toxin batches. [Copyright &y& Elsevier]

Abstract: We are reporting the use of a xylocain test before the injection of botulinal toxin within the "facial paralysis and botulinal toxin" multidisciplinary consultation of the Caen regional hospital. Our assessment is about 16 patients tested. This test is based on a digital film and a questionnaire. It is often proposed when toxin is first used. It influences the patient''s choice. It permits a better understanding of the toxin action by the patient, it reassures. It is reliable for the practitioner even though we do not have a mathematical correlation between the xylocain volume and the botulinal toxin volume. Simple and far, it is a help for the patient and the practitioner before a delicate injection of botulinal toxin. [Copyright &y& Elsevier]

Abstract: This study corroborates that the resting tone is indeed increasing with age. And that like in the Face Recurve® concept, the deep fat is expelled superficially because of mimic muscle shortening. Botulinum toxin is therefore described for a new indication: resting tone decrease in order to slow down muscle shortening and consequently structural aging. Injections can be performed very early in the ageing process, when it is only visible in contraction, before the appearance at rest of wrinkle. Precision of the injection is related to the recent determination of motor end plate location in every mimic muscle. Finally, a new possibility for botulinum toxin injection is the blockage of muscular regeneration in order to stabilize the section of the age marker fascicles performed in the Face Recurve® concept. This new indication is also useful in reconstructive surgery for treatment of the marginal mandibular lip deformity in patients with chronic unilateral facial palsies. [Copyright &y& Elsevier]

Abstract: Cell ageing is responsible for the increasingly creased appearance of our skin. The ageing of the structures of the face is attributed primarily to the effect of gravity on the tissues. The theory expounded below sets out to prove that the main and initial cause of this ageing is the repeated contractions of the mimic muscles. This concept attributes only a secondary role to gravity in the ageing process, which is initially brought about by muscular contractions. An MRI study recently made it possible to demonstrate the anterior convexity curve of the mimic muscles in the young subject. This curve is due to the existence at the back of these muscles of a deep fat pad. In the young subject, the extent of its convexity and its location give a specific, youthful character to the movements, in terms of direction and amplitude, of the facial muscles. With age, the muscle gradually straightens and shortens due to the repeated contractions that expel the underlying fat and increase the tonus at rest. The application of these new findings to the ageing of the face gives rise to new technical possibilities both in the field of medicine and aesthetic surgery. These new techniques have the same targets: segments of the mimic muscles (maintain over time a good muscular curve and a low tonus at rest) and the underlying fatty convexities. As far as medicine is concerned, the combination of botulinum toxin and filling has proved its worth. But two technical elements are new: the filling products must, at several points, be injected primarily behind the muscle to treat the depressions naturally and restore the initial curve of the overlying muscle. A very low number of units (a quarter to one unit) of botulinum toxin must be injected into certain muscles to diminish the tonus at rest of these muscles without diminishing their strength in maximum contraction. In surgery, new possibilities to treat premature ageing include procedures that combine segmentary muscular weakening, micro liposuctions and retromuscular reinjections. The advantage with regard to the medical procedures is greater stability over time and the greater precision of these muscular actions (one third of a muscle can be weakened for example) and the fat reinjections can be more stable. These procedures can be performed under local anesthesia. In cases of more advanced ageing, surgery offers new treatment possibilities that include, for the midface region, the concentric malar lift. It replaces, on the orbital rim, the sub-orbicularis oculi fat that has descended eccentrically as a result of the contractions of the orbicularis oculi muscle. The procedure, using the subperiosteal detachment plane, is therefore stable over time. At the same time, specific muscles are weakened. The aims of restoring fatty volumes and muscular tonuses are thus achieved. Similarly, in the neck, the platysma muscle is specifically weakened. Each area is studied in line with its specificities. For the first time, the skin tension of the facelift has no more to be maximum to treat the relief of the jawl line, of the palpebro malar groove and so on. The skin tension becomes moderate, just to remove the excess of skin. The relief is faded with the specific muscular and fatty action. The name of this new concept is Face Recurve®. [Copyright &y& Elsevier]

La « section biologique », par dénervation chimique, réalisée par la toxine botulique, produit un traitement très efficace, modulable, et durable des rides d’expression, notamment du tiers supérieur du visage, qui sont traitées souvent avec un risque supérieur et une durabilité moindre par la chirurgie ou les autres traitements médicaux alternatifs. Son emploi depuis plus de 20 ans dans de nombreuses pathologies, et depuis 13 ans en dermatologie et chirurgie plastique, n’a jamais, provoqué de complications sévères ou de séquelles, mais uniquement des effets secondaires réversibles. L’emploi, notamment dans nos spécialités, de faibles quantités de toxine (peu de volumes et peu d’unités par point d’injection), ont permis de diminuer la fréquence des risques, certains étant actuellement anecdotiques. La seule complication sérieuse, dans le cadre esthétique est le ptosis palpébral, mais il est de plus en plus rare. Une meilleure connaissance de l’anatomie musculaire, et les améliorations techniques actuelles ont largement diminué ce risque. Dans nos deux études multicentriques sur les rides glabellaires de 2002 à 2004, sur respectivement 102 et 100 patients, nous n’avons retrouvé aucun blépharoptosis. En revanche, si ces rides d’expression sont associées à une ptose des tissus cutanéomusculaires et graisseux, et/ou à des rides profondes, non hyperkinétiques, et à d’autres altérations de la surface, la chirurgie et/ou les traitements de surface sont souhaitables. Loin de s''opposer aux liftings supérieurs, médiofaciaux et cervicomandibulaires, la toxine botulique souvent associée, bonifie leurs résultats. Elle apparaît de plus en plus comme un des gestes essentiels à la pérennisation de ces résultats. L''évolution actuelle et future se fait vers un lifting complet, mais ciblé, naturel, le moins invasif possible, et une association avec des gestes médicaux puissants avant tout comme la toxine botulique. Si ces rides nécessitent un traitement médical de surface, la toxine botulique, souvent injectée trois semaines avant ce traitement, met au repos les muscles concernés, dans le territoire où sera réalisé ce traitement. Les effets des lasers, peelings, et des comblements dermiques, sur les ridules persistantes dans les régions concernées par ces muscles, sont alors souvent optimisés, et plus durables. Cette association médecine–chirurgie est l’un des exemples majeurs de l’évolution de la chirurgie plastique et esthétique en 2004. [Copyright &y& Elsevier]

En plus de l’analyse habituelle du visage au repos, l’intérêt de l’analyse fonctionnelle et dynamique, avec l’aide de la palpation est expliquée. Un point clef dans la répartition des zones d’injection est de décider de privilégier la position haute des sourcils par rapport à l’estompement des rides frontales. Pour faire ceci au mieux, une nouvelle segmentation de l’anatomie fonctionnelle du muscle frontal est décrite et le rôle du muscle procerus comme antagoniste du muscle frontal médian inférieur est analysé. Pour relever le tiers moyen du sourcil, la partie latérale du muscle corrugator est injectée avec une technique spécifique pour éviter d’affaiblir le muscle frontal sus-jacent et bien sûr le muscle releveur de la paupière sous-jacent. Pour relever plus efficacement la queue du sourcil et mieux estomper la patte d’oie, différents points d’injection sur le rebord orbitaire externe sont pratiqués sans risquer d’atteindre les muscles oculomoteurs. L’adoucissement du creux des cernes est réalisé par l’injection d’un faisceau particulier (pars superior malaris) du muscle orbicularis oculi. Grâce à une bonne analyse fonctionnelle du visage et grâce à l’instrument extraordinaire qu’est la toxine botulique, il est maintenant justifié de pouvoir passer d’une pratique « prêt à porter » à une conception « haute couture » de son utilisation, c’est-à-dire adaptée à chaque patient. [Copyright &y& Elsevier]

Connaître l’anatomie des muscles du tiers supérieur du visage et leur fonction, comprendre la fameuse balance musculaire frontale, considérer les remaniements anatomiques et histologiques induits par le vieillissement au niveau de la surface cutanée et de la fonction musculaire des muscles peauciers sous-jacents, sont primordiaux pour mieux dominer l’apport thérapeutique remarquable procuré par la toxine botulique, car existe dans son utilisation un risque opérateur-dépendant non négligeable. [Copyright &y& Elsevier]

The fight against aging is carried on several levels: a healthy life, anti-aging medicine as well as fight against aging symptoms. In our days, plastic surgeons anxious to find answers to the specific demands of their patients must invest themselves in other areas, to at least, acquire the knowledge or, to enable them to practice the necessary skills to meet those needs. Once it is agreed upon that a healthy life is the forerunner of any meaningful anti-aging program, the forceful demands of patients for anti-aging treatments must be treated with great care. This specialty is presently at an embryonic stage. Today the research is focused on providing the best well being while aging rather than stopping it. In addition, to date, certain hormonal treatments have not proven their efficacy and safety. As for the prevention of facial aging, the injection of botulinum toxin A presents the most advanced technique known. It acts on aging resulting from muscular hyperkinetics. Furthermore, because of increased hydration of the skin it delays actinic aging. This technique has lots of room for improvement: on the physician side by developing a better understanding of functional anatomy to target the injections to suit each patient’s case, and on the supplier side by improvement of the product. [Copyright &y& Elsevier]

The combining of a traditional resurfacing technique (trichloracetic or phenol peel) with 2 recent technological advances (endoscopic forehead plasty, botulinum toxin) may enhance the forehead rejuvenation in a more natural way. The desapointing results of some of our earlier results on a serie of 70 concecutive foreheadplasties can probably be attributed to the weakness of the suspension through percutaneous sutures. This has been remedied since 1998 by the systematic use of transosseous suspensions. The growing success of botulinum toxin explains the noticable decrease of endoscopic surgery. This type of procedure is now used to correct significant frontal ptosis requiring an uplifting of no more than 1,5 cm, thereby avoiding the unnatural results encountered in many publications. Some benefits can be obtained by the way of a transpalpebral approach without using the endoscope; nowadays, upper blepharoplasties are almost systematically done in the majority of our cases in order to obtain the most natural result. Light peels and botulinum toxin injections can maintain this result relatively easily. [Copyright &y& Elsevier]