ptosis is due to paralysis of which muscle

In the "converging arrows" pattern, there is mainly approximation of the eyebrows, with little or no medial or lateral depression or elevation. A bitemporal defect suggests a lesion of the sellar region (pituitary tumor) with cavernous sinus involvement. Thus, different protocols or strategies were not compared for different clinical outcomes. Before we start talking about each muscle, we would like to remind you of the main feelings that we can express with our face: joy, suspicion, anger, disgust, surprise, fear, and in between there are countless attitudes in between [3]. Springer Nature - PMC COVID-19 Collection, Softening of horizontal forehead lines and weakening of the single eyebrow lift, Frontalis and orbicularis muscles, mainly corrugators and procerus secondarily, Smoothing of periorbital lines and lifting of eyebrow tails. Botulinum toxin, Cosmetic surgery, Upper face. The authors who proposed the classification suggest that the best approach for these cases is to inject BoNT into the corrugators and orbicularis of the eyelids in the medial part of the frontalis muscle (Fig. Ask the patient to alternately occlude each eye to localize the nature of the diplopia. Besides the force exerted by the corrugators and the procerus, there is important participation of the medial part of the orbicular. Tamhankar MA, Volpe NJ. Carotid-cavernous fistula: current concepts in aetiology, investigation, and management. Received 2021 May 5; Accepted 2021 Jul 8. Repeat imaging was not done. Singhi et al9 reported two children who presented with sudden onset ptosis due to midbrain NCC. 2019:9185603. Evidence of ptosis suggests a third cranial nerve palsy. 11:63-72. But the patient had no other neurological deficit such as long-tract signs or diplopia which is expected from a lesion in such a compact structure. 2018 Oct 18; Joyce C, Le PH, Peterson DC. 2019. The third cranial nerve supplies the levator muscle of the eyelid and four extraocular muscles: the medial rectus, superior rectus, inferior rectus, and inferior oblique. [QxMD MEDLINE Link]. The studies selected in the first step were read in their entirety, and again the eligibility criteria were applied, determining, then, the inclusion or not in the research. Ptosis because of midbrain NCC is one of the rare presentations. Federal government websites often end in .gov or .mil. official website and that any information you provide is encrypted J Child Neurol. Sharma R, Gaillard F. Nothnagel Syndrome. Treasure Island, Florida: StatPearls Publishing; Updated 2021 Aug 27. Underlying diagnoses such as diabetes, pituitary macroadenomas, and multiple sclerosis can help localize the cause of third nerve palsies, when known. The descriptions of universal models do not take into account the individual characteristics that are present in the different muscle contraction patterns. Avoiding Complications on the Upper Face Treatment With Botulinum Toxin Andrew G Lee, MD Chair, Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital; Clinical Professor, Associate Program Director, Department of Ophthalmology and Visual Sciences, University of Texas Medical Branch School of Medicine; Clinical Professor, Department of Surgery, Division of Head and Neck Surgery, University of Texas MD Anderson Cancer Center; Professor of Ophthalmology, Neurology, and Neurological Surgery, Weill Medical College of Cornell University; Clinical Associate Professor, University of Buffalo, State University of New York School of Medicine sharing sensitive information, make sure youre on a federal Braz and Sakuna (2010), who suggested these patterns, reported that patients presenting this pattern most often also have rectified eyebrows, with ptosis of the tail in some cases. Particular cases include: Ptosis (eyelid) Ptosis (chin) Ptosis (breasts) Visceroptosis, of the abdominal viscera . A literature search was conducted using two electronic databases (MEDLINE and PubMed). Evidence of vision loss with a third cranial nerve palsy may implicate a common underlying mechanism such as papilledema, or localize lesions in the sellar region (pituitary apoplexy) or orbital apex. Complete ptosis is due to complete oculomotor nerve palsy. We recommend treatment with the classic five-point injection points, as shown in Fig. If you log out, you will be required to enter your username and password the next time you visit. Gastroptosis, of the stomach; Nephroptosis, of the kidney; See also. Trindade De Almeida A, Secco L, Carruthers A. Sundaram H, Signorini M, Liew S, et al. Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, North American Neuro-Ophthalmology SocietyDisclosure: Nothing to disclose. However, it is suggested that the commented parameters and safety areas be incorporated into daily practice so that the possibilities of complications are minimized as much as possible. Knowledge of the anatomy and the normal physiology of the eyelid makes it easier to understand the various ways in which ptosis may present. Ptosis is caused by weakness of elevator muscles of eyelids, either levator palpabrae superioris (LPS) or muller muscle. Particularly on the upper face treatment with BoNT offers predictable results, has few adverse effects, and is associated with high patient satisfaction. However, in ischemic lesions, the . Her routine biochemical parameters, complete haemogram, renal and liver function tests were normal. After investigation (especially MRI) 1) Tuberculomait is another common central nervous system (CNS) infection in this part of the world. The injection in this area should be adapted to the wrinkle pattern; however, the injections should be superficial, respecting the limit of 1 cm from the orbital border and 1.5 cm from the lateral canthus to prevent the product from spreading to undesired areas, reaching, for example, the lateral rectus muscle, innervated by the abducens nerve, which can lead to paresis of this muscle and diplopia (Figs. J Neurosurg. The muscles of facial expression are inserted directly on the skin surface, so repetitive contraction causes characteristic rhytids to form perpendicular to the direction of the vector of contraction [2, 16]; Fig. A weakness in the eyelid muscles can occur in some rare muscle conditions such as myasthenia gravis or myotonic dystrophy. As a library, NLM provides access to scientific literature. Contraindications and complications with the use of botulinum toxin. Available at https://eyewiki.aao.org/Acquired_Oculomotor_Nerve_Palsy. Color vision loss disproportionate to high contrast visual acuity deficits may implicate a third cranial nerve palsy and ipsilateral optic neuropathy. There was no neck rigidity or Kernig's sign. : a comparison of eye care in an accident and emergency department with a dedicated eye casualty. Fiona Costello, MD, FRCP Associate Professor, Department of Clinical Neurosciences, Neuro-opthalmologist, Clinical Neurologist and Clinical Investigator, Hotchkiss Brain Institute, University of Calgary Faculty of Medicine, Canada CT imaging is needed acutely in the setting of ICH or hydrocephalus with raised intracranial pressure. There are no conflicts of interest to declare regarding this article. Prominent fatigue and variability with respect to ptosis and diplopia often implicate a neuromuscular junction abnormality in lieu of a third cranial nerve palsy. and transmitted securely. Matarasso SL, Matarasso A. Treasure Island (FL): 2021 Jan. [Full Text]. Bilateral ptosis: an atypical presentation of neurocysticercosis Third Nerve Palsy (Oculomotor Nerve Palsy) Treatment - Medscape 3.1 General treatment 3.2 Surgery 3.2.1 Procedures that lift the temporal portion of the brow: 3.2.1.1 Direct temporal browplasty 3.2.1.2 Indirect browpexy 3.2.2 Procedures that lift the entire brow: 3.2.2.1 Direct browplasty 3.2.2.2 Mid forehead lift 3.2.2.3 Pretricheal forehead lift 3.2.2.4 Endoscopic forehead lift 3.3 Surgical follow up Brow Ptosis and Repair - EyeWiki StatPearls. Systemic conditions such as Graves Disease can cause a restrictive orbitopathy which may mimic manifestations of a third cranial nerve palsy. This type of ptosis often results directly from conditions such as Horner syndrome or third cranial . Botulinum toxin can migrate inadvertently due to multifactorial causes, involving adjacent muscles and having a series of unpleasant side effects. The main muscles that form the glabellar complex include corrugators and orbicular of the eyelid (approximate and depress the eyebrows), procerus and depressors of the eyebrow (depress), and the inferior fibers of the frontalis (elevate the eyebrows). Oculomotor nerve palsy | Radiology Reference Article - Radiopaedia.org Some medications such as immune check point inhibitors (inflammatory), vaccinations (inflammatory), tumor necrosis factor alpha inhibitors (demyelinating), and bisphosphonates (inflammatory) may cause manifestations of third nerve palsies or, in the case of restrictive orbital lesions, mimic third nerve palsies. Sethi et al (2020) in a cohort of patients reported the overall incidence of eyelid ptosis equals 0.71% and eyebrow ptosis 0.98% [12]. Contrast SPGR study showing dorsal midbrain ring-enhancing cystic lesion with perilesional oedema in axial (A), saggital (B) and coronal (C) sections. Prednisolone was tapered off over the next 3weeks. Lateral canthal wrinkling (crows feet) may represent one of the earliest signs of aging. Radiopaedia.org. [QxMD MEDLINE Link]. Currently, botulinum toxin injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face [1]. Orbital signs such as proptosis and arterialized conjunctival vessels, might suggest an orbital process mimicking a third nerve palsy due to muscle restriction, including Grave's Disease, orbital inflammation, orbital infiltration, or a carotid cavernous sinus fistula (CCF). Available at https://emedicine.medscape.com/article/1198462-overview. A predominance of arched brow positioning was observed in patients with a lateral pattern. Full knowledge of the anatomy of the facial muscles, proper marking, injection techniques, and knowledge of the mechanism of action of the product being used are the best ways to avoid such problems. Thus, the purpose of this review is to present the main complications and most common unwanted effects from the use of botulinum toxin and to demonstrate the safe areas for application of BoNT on the upper face. Causes The lifting of the eyelid is carried out due to the functioning of a special muscle that raises the upper eyelid (levator), which is innervated by the oculomotor nerve. [QxMD MEDLINE Link]. The .gov means its official. The "V" pattern (Fig. Ptosis refers to a drooping or inferior displacement of the upper eyelid with associated narrowing of the vertical palpebral fissure. She noticed drooping of both eyelids which progressed over 12days to cover most part of her eyes. Courtesy of Tyler Henry, MD, Medical Illustrator (tylerhenrymd.com). Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) (2019) Cochrane handbook for systematic reviews of interventions, 2nd edn. Ptosis may be due to either weakened eye muscle or impairment of the nerves that control the eyelid muscles. Although the exact dose of toxin known to cause toxicity is unknown, it is generally agreed that single doses of BoNT-A should not exceed 500 units [21]. Moreover, the lymphatic drainage in this region may be impaired and cause eyelid edema, especially in cases of patients with great orbicular muscle laxity and long wrinkles that extend to the malar region [3, 5, 19]. Complications of botulinum toxin A use in facial rejuvenation. Directed vertically, it raises the eyebrow and is responsible for the mimicry of surprise, interest, or concern. 27 (6):759-66. Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Canadian Ophthalmological Society, Canadian Society of Oculoplastic Surgery, Chinese Canadian Medical Society, European Society of Ophthalmic Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Statistical Society of CanadaDisclosure: Nothing to disclose. Share cases and questions with Physicians on Medscape consult. Ptosis: Due to paralysis of LPS (levator palpebrae superioris) muscle; Ocular deviation: In case of third-nerve palsy, the lateral rectus and superior oblique are spared, and their unopposed action brings the eye in a "down and out" position. Then the patient is asked to look up and the amount of upper lid excursion is measured with a ruler held in the other hand by the examiner. Classically, patients present with diplopia and physical exam findings ipsilateral to the oculomotor nerve (CN III) lesion: "down and out" ocular positioning. [QxMD MEDLINE Link]. BoNT is an endotoxin produced by the anaerobic bacterium Clostridium botulinum. The brow depressor muscle is, for many, part of the corrugator muscle, extending from the nasal portion of the frontal bone to the skin of the medial portion of the brow, its belly being positioned about 1 centimeter above the medial canthal ligament [23]. 12 (1):23-7. Characteristic features of congenital ptosis. Inclusion in an NLM database does not imply endorsement of, or agreement with, Oral steroid, prednisolone 40mg was given for 1week. Normal value of MRD is 4-5 mm. Various other causes of similar presentations were reported such as midbrain glioma, hematoma7 and infarct.8 Oculomotor involvement due to NCC is unusual and bilateral ptosis due to brainstem parenchymal involvement has rarely been reported. Contraction of the procerus muscle lowers the medial aspect of the eyebrow and is the main contributor to the horizontal lines, whereas contraction of the corrugator muscle draws down the medial aspect of the eyebrow and is primarily responsible for vertical lines [10]. The literature research considered published journal articles (clinical trials or scientific reviews). Eye (Lond). A case of fluctuating ptosis presenting like myasthenia was seen by Netravathi et al.10 Third cranial nerve palsy due to midbrain NCC which rapidly deteriorated on tapering steroids was also reported by Kim et al.11. Suzana Matayoshi, Email: moc.liamg@ihsoyataM.anazuS. In the first step, the titles and abstracts of the studies found from the search described in the previous item were read, and the eligibility criteria previously defined in this review were applied. Brow ptosis is the descent of the eyebrow from its normal anatomical position down to a point at which its appearance is cosmetically displeasing, or visual field deficits develop as a result of excess soft tissue pushing downwards on the eyelid. [QxMD MEDLINE Link]. Acquired Ptosis: Evaluation and Management - American Academy of Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. . A case of fluctuating ptosis presenting like myasthenia was seen by Netravathi et al. Eye Brain. However, amild and moderate one, surgery should be delayed until the age of 34 years, when accurate measurements are possible. See the beautiful world with beautiful eyes. Frontalis sling operation (Brow suspension). Lid crease is either diminished or absent. Rajshekhar V, Haran RP, Prakash GS, et al. MRI with T1W, T2W, fluid attenuated inversion recovery (FLAIR) and 3D spoiled gradient recalled echo sequence (SPGR) sequences was done. CNIII, CNIV, CNV1, CNV1, CNV2 (posterior), sympathetic innervation. 8600 Rockville Pike Traumatic dehiscence or disinsertion of the aponeurosis. Matheus Rodrigues has nothing to disclose. Cancer Neurological disorder Age; eye muscles weaken as they age, increasing the chance of the eyelids drooping. Bilateral symmetric ptosis without any other neurological symptoms or signs is a rare presentation of NCC and it should be considered as a differential diagnosis of ptosis especially in endemic regions. Singapore Med J. [QxMD MEDLINE Link]. Nerve conduction studies (NCS), electromyography (EMG), repetitive nerve stimulation (RNS) studies and single fiber EMG. Ptosis (or blepharoptosis) is a drooping or falling of the upper eyelid. Lateral depression of the eyebrows occurs simultaneously. Henderson AD, Miller NR. Neuroanatomy, Cranial Nerve 3 (Oculomotor). 2021 Oct 31; Accessed: December 31, 2021. Third cranial nerve palsies can cause variable patterns of diplopia, and manifestations of horizontal and vertical misalignment will reflect to what extent elevation, adduction, and depression of the eye are impaired. The dosage depends on the depth and extent of the hyperdynamic rhymes, and to determine the distribution of the points, the patient is asked to make a forced smile. Tuberculomas are usually irregular, solid or disk shaped, and >2cm in size. Goodwin J, Lee AG, Ing EB, Al Othman BAM. Over time, however, repeated contractions cause horizontal wrinkles to form in the overlying skin. Badakere A, Patil-Chhablani P. Orbital Apex Syndrome: A Review. Fig.6b,6b, in the shape of an inverted triangle. A small percentage of patients present asymmetries within the described patterns, and these variations should be taken into consideration when marking the points. Cranial nerve dysfunction due to parenchymal cysts is uncommon. All types of studies were defined as eligible, as follows: case reports or case series, retrospective studies, prospective studies, randomized clinical trials, literature reviews, protocols, and guidelines. A total dose of 10 to 30 units can typically be given divided between 2 and 3 injection sites per side. Braz AV, Sakuma TH. Muscle Weakness in Adults: Evaluation and Differential Diagnosis The "U" pattern is usually the second most common. Ptosis (eyelid) - Wikipedia Drooping of one or both upper lids more often since birth of variable severity (mild, moderate, or severe). Philadelphia: Wolters Kluwer Health; 2022. Perilesional oedema was also present. Thus, this review aims to describe the main complications of treatment with BoNT on the upper face and to present a practical guide based on current evidence on how to avoid them. James Goodwin, MD is a member of the following medical societies: American Academy of Neurology, Illinois State Medical Society, North American Neuro-Ophthalmology Society, Royal Society of MedicineDisclosure: Nothing to disclose. Horner syndrome may be the result of another medical problem, such as a stroke, tumor or spinal cord injury. (Fig.77e). Illustration of a partial right oculomotor nerve palsy demonstrating incomplete ptosis, hypotropia and mydriasis of the right eye. Levator palpebrae muscles are innervated by the central caudal nucleus, which lies most dorsocaudally in the oculomotor nuclear complex 1, 10.Hence, bilateral ptosis could occur with a midline lesion in the dorsocaudal midbrain 1, 7.Ventral expansion of such a lesion would impinge upon other subnuclei of the oculomotor nuclear complex [1].A neuroanatomic study by Henn et al. The ptosis seen in paralysis of the levator palpebrae superioris is usually more pronounced than that seen due to paralysis of the superior tarsal muscle. Usually, ptosis occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumors, or infections. Careers, Unable to load your collection due to an error. Jirawuthiworavong GV Noel MC, Yen MT, Thyparampil P, Marcet MM, Burkat CN. Aberrant facial nerve regeneration following facial nerve palsy may cause facial nerve synkinesis and ptosis. Figure Figure77 demonstrates each one and the suggested points for an individualized injection. (Figs.1,1, ,3).3). 1976 Aug. 45 (2):169-80. Studies describing complications secondary to other than cosmetic BoNT applications were excluded. 35 (3):335-41. Klein AW. Vartanian AJ, Dayan SH. Accessibility Netravathi M, Banuprakash AS, Khamesra R, et al. Complications of botulinum toxin and fillers: A narrative review. Horner's syndrome, Ophthalmoplegic migraine, and Multiple sclerosis. Patterns of contraction of the frontalis muscle: a pilot study. The use of handheld smart phones for written communication is becoming ubiquitous in modern society. There is an ongoing turnover of neuromuscular junctions; however, that is enhanced by toxin exposure such that muscular function begins to return at approximately 3 months and is usually complete by 6 months [2, 5]. However, the amount of levator resection required is always less than the congenital one of the same degree. Most cosmetic applications of BoNT involve the upper face, and it is usually the motivation for facial aesthetic treatment. https://emedicine.medscape.com/article/1198462-overview, https://read.qxmd.com/doi/10.53347/rID-54279, https://eyewiki.aao.org/Acquired_Oculomotor_Nerve_Palsy, https://eyewiki.aao.org/Cavernous_Sinus_Syndrome#cite_note-:1-2, https://www.medscape.com/answers/1198462-111321/how-is-fourth-cranial-nerve-palsy-diagnosed-in-the-setting-of-third-cranial-nerve-palsy-oculomotor-cranial-nerve-palsy, https://collections.lib.utah.edu/details?id=1578889&page=10&facet_setname_s=ehsl_novel_lee, https://eyewiki.aao.org/Oculomotor_Synkinesis#cite_note-:0-4, https://eyewiki.aao.org/Carotid_Cavernous_Fistula, https://eyewiki.aao.org/Myasthenia_Gravis, College of Physicians and Surgeons of Alberta, North American Neuro-Ophthalmology Society, Royal College of Physicians and Surgeons of Canada, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery. Fig.22 shows the force vectors of the facial muscles. OnabotulinumtoxinA treatment of mild Glabellar lines in repose. Evidence of anisocoria, with a mydriatic pupil or tonic pupil with light near dissociation ipsilateral to the third cranial nerve palsy will help localize the lesion; the presence of a concomitant ipsilateral relative afferent pupil defect may implicate a lesion of the orbital apex. Illustration of common causes of an oculomotor nerve palsy. In bilateral cases it can be determined by measuring the amount of cornea covered by the upper lid and then subtracting 2 mm. The superior oblique muscle is innervated by cranial nerve IV and the lateral rectus muscle by cranial nerve VI. A 45-year-old woman presented to us with acute onset bilateral ptosis of 4days duration (figure 1A). Currently, botulinum toxin (BoNT) injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face. Nervous System Medicine Flashcards | Quizlet Courtesy of Tyler Henry, MD, Medical Illustrator (tylerhenrymd.com). Demonstration of the safety marking (B) at the lowest allowed point of the right belly of the frontalis muscle and (B) the uppermost point of the right belly of the frontalis muscle. Other features include mild enophthalmos, loss of cilio-spinal reflex, heterochromia, i.e., ipsilateral iris is lighter in color, pupil is slow to dilate, and there occurs slight elevation of the lower eyelid. Dr. Andr Borba reports grants from Allergan, Inc. as a speaker. Cerebrospinal fluid analysis did not reveal any abnormality other than ELISA for immunoglobulin M antibodies for cysticercus antigen which was positive. Commonly known as "droopy eyelid," ptosis can affect one or both eyes and may occur due to trauma or illness (acquired ptosis) or be present from birth (congenital ptosis). Chua HC, Tan CB, Tjia H. Aberrant regeneration of the third nerve. Ptosis - Moorfields The prominence of the palpebral bags may occur due to greater laxity of the orbicular muscle and consequent projection of the fat bags. Isolated fascicular third nerve palsy. Levator palpebrae superioris muscle Levator palpebrae superioris muscle Extrinsic eye muscle. It is associated with congenital weakness(maldevelopment) of the levator palpebrae superioris(LPS) muscle. This is performed in patients having severe one with no levator function. Patterns of frontal lines according to Braz and Sakuna's (2010) classification and BoNT injection points. After ice application, improvement of ptosis suggests a disorder of the neuromuscular junction as a possible mimic of a third cranial nerve palsy. Ptosis | Radiology Reference Article | Radiopaedia.org Omoigui S, Irene S. Treatment of ptosis as a complication of Botulinum Toxin Injection. Etienne Benard-Seguin, MD Chief Resident Physician, Department of Ophthalmology, Cumming School of Medicine, University of Calgary, CanadaDisclosure: Nothing to disclose. CT imaging of the chest is needed to check for hilar lymphadenopathy in the case of sarcoid, and thymic hyperplasia/thymoma in suspected MG. due to neuropathy affecting levator palpebrae superioris. Hyperdynamic rhytids, particularly on the upper face, not only can be visually undesirable but, over time, also can result in dermal atrophy and corresponding static facial rhytids. Courtesy of Tyler Henry, MD, Medical Illustrator (tylerhenrymd.com). Social implications of hyperfunctional facial lines. (2011) and injection points of BoNT. Mild ptosis, where the eyelid droops but does not cover the pupil, is a cosmetic . This can alter the location of the clinical effect and increase the adverse effects [9, 10]. Fig.2),2), forming unwanted horizontal, vertical, and oblique wrinkles. Barry BJ, Whitman MC, Hunter DG, Engle EC, Adam MP, Ardinger HH, et al. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic. Patients older than 50 years may experience third cranial nerve palsies secondary to giant cell arteritis (GCA); therefore, asking about transient vision loss, headache, scalp pain, weight loss, muscle aches, and jaw claudication are important facets of the history to explore so as not to miss this vision-threatening/life threatening diagnosis. We recommend injecting at 7 points, as shown in Fig. Multiple cranial nerve palsies with vision loss in the ipsilateral eye can implicate a lesion of the orbital apex. Botulinum toxin injection for the treatment of facial wrinkles is one of the most frequently performed cosmetic procedures in Cosmiatry. Fig.5c,5c, so as not to compromise the movement of the eyebrow tail. The total pattern (Fig. In this area, the most common manifestations of aging of the upper face occur: horizontal forehead lines, glabella expression lines, and periocular ("crow's feet") wrinkles. However, a rough estimate in different grades of ptosis can be made: Moderate: Depending on the level of LPS function the amount of LPS to be resected is as below: Severe: Fair levator function: 23-24 mm (maximum LPS resection). de Maio M, Wu WTL, Goodman GJ, Monheit G. Facial assessment and injection guide for Botulinum Toxin and injectable hyaluronic acid fillers: Focus on the Lower Face.

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