Just a few short years ago the compilation of different injection
techniques for the cosmetic use of the then-available botulinum
neurotoxins (BoNTs), namely BOTOX®
Cosmetic and MyoblocTM/
NeuroblocTM, appeared to be a daunting undertaking. Because of the
exponential developments in the clinical use of botulinum toxin A
(BoNTA), this second edition quickly became a foregone conclusion.
Maintaining the original mission of an instructional manual, this
updated edition attempts to record the improvements that naturally
have evolved from earlier injection techniques. It also introduces
newer and innovative ways to utilize the different BoNTs that are
presently available worldwide.
In the United States, the glabella remains the only area of the face
that is approved by the FDA for the cosmetic use of BOTOX®
Cosmetic,
now identified by its nonproprietary name of onabotulinumtoxinA.
Consequently, except for the glabella, all the cosmetic injection tech-
niques described in this edition, as in the previous one, apply to nonap-
proved, off-label indications, which makes this book unlike most other
textbooks in medicine.
It is sobering to realize that throughout human existence men as well
as women have always sought ways to improve their appearance. Dr.
Caroline Koblenzer takes us through a historical interpretation of
beauty and the beautiful and how the use of BoNT can supplement our
patients’ incessant attempts to maintain the appearance of youthful-
ness. Faced with an overwhelming amount of new scientific and tech-
nical information, Dr. Roger Aoki updates us with some of the latest
developments in the pharmacology and immunology of BoNTs.
Understanding functional anatomy cannot be over emphasized and
Dr. James Spencer has made a concerted effort to apply his knowledge
of anatomy in a meaningful and practical way as it relates to the use of
BoNTs. The nuclear chapters on treating the face, neck, and chest with
injections of BoNTA have been reorganized and expanded, assimilat-
ing a number of improved injection techniques with the plethora of
recently published clinical articles.
Dr. Woffles Wu, one of the early initiators of the intradermal use of
BoNTA, has complemented this edition with his innovative techniques
of muscle contouring and skin redraping. Reducing muscle bulk and
girth of various parts of the body are techniques that are frequently
practiced in the East and are quickly becoming popular in the West. Dr.
Kevin Smith continues to impress us with avant-garde uses of BoNTA
for treating Raynaud’s phenomenon and other painful conditions and
scars as well as describing potential techniques for lifting the female
breasts with injections of BoNTA. He also presents some tips on the
management of an acute overdose of BoNTA.
OnabotulinumtoxinA (BOTOX®
Cosmetic) is no longer the only
BoNTA approved in the United States. As anticipated in the first edi-
tion, DYSPORTTM (abobotulinumtoxinA) finally made its debut in the
U.S. market about a year ago. Dr. Gary Monheit, who headed the U.S.
clinical trials for onabotulinumtoxinA, has updated the injection tech-
niques for its clinical use. He also previews the pharmacology of the
noncomplexed (naked) BoNTAs and introduces incobotulinumtox-
inA, a “naked” BoNTA currently used in Europe, Mexico, and South
America and soon to be introduced into the U.S. market. He also gives
us a peek into the future with as much information currently permis-
sible about a topical BoNTA presently undergoing phase II and III
clinical investigation. The chapter on BoNTB (rimabotulinumtoxinB),
the only nontype A neurotoxin approved by the FDA, has been updated
by Dr. Neil Sadick. Dr. Dee Anna Glaser, current President and Found-
ing Member of the International Hyperhidrosis Society, has revised
and updated the chapter on hyperhidrosis.
Another enhancement to this edition is Dr. David Goldberg’s expert
rendition of medicolegal considerations for those physicians who treat
patients for cosmetic purposes. This important aspect of medical prac-
tice rarely is addressed, but there are pertinent issues of which we
should be aware.
Particular recognition and a special expression of gratitude is due to
Lisa Van Horn for her organizational skills and secretarial expertise
that facilitated the completion of this book. Finally, we are all indebted
to those physicians who have treated and continue to care for patients
with BoNTs for therapeutic and cosmetic purposes. Their commitment
to the improvement of their patients through the advancement of
sound and effective medical care should be lauded and emulated.
