Accordion wrinkle treatment through the targeted use of botulinum toxin injections.

UNLABELLED: The term "accordion facies" is used to define a face that has been streaked by an extended network of wrinkles stretching from the orbital frame up to the temples and neck. Although the origin of these wrinkles seems to be the mime muscle effect, it also may be linked to the presence of acetylcholine skin receptors in the superficial skin. This would certainly explain the reason for the presence of these wrinkles far from the muscle areas. Therefore, very superficial and targeted injections of diluted botulinum toxin A can be offered. In the case of strongly dehydrated skin, the toxin may be combined with a weak or not reticulated hyaluronic acid. The use of thin cannulas offers an advanced treatment especially in the resistant crow's feet area with a single entry point and a lower risk of ecchymotic incidents. The results are quite impressive and offer real new options in the management of the aging process. The main drawback remains the risk of unexpected diffusions to the great zygomatic muscle, with some distortion in the extreme smile. Therefore, dilution (up to 3 times) and very precise injections are strongly recommended, especially in the para-commissural area. This report presents a case study of 44 patients who received this treatment, with a follow-up period of 1-25 months. To date, these particularly striking facial distortions had not received a satisfactory answer. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .