An interview with Steven Fagien, MD, FACS

After applying botulinum toxin Type A to a variety of facial areas for more than 20 years, oculoplastic surgeon Steven Fagien, MD, FACS, is known as a leader in its use. While Fagien’s surgical practice is limited to performing aesthetic eyelid plastic surgery, a sizable component of it is made up of applications of injectable agents, such as botulinum toxin.

Fagien, who went to medical school and spent his residency in ophthalmology at the University of Florida, studied oculoplastic surgery at the University of Illinois. He started working with botulinum toxin as a resident. “Even before my fellowship in oculoplastics, I was fascinated by this drug,” he says. “Among those who were using botulinum toxin for a variety of facial spastic/eyelid spastic disorders, many of us realized that there appeared to be some cosmetic improvement with its use, despite the fact that that wasn’t the primary goal. There were some positive cosmetic ramifications in many of our patients that, at first, were considered as secondary effects of the toxin.”

Since 1997, Fagien has taught courses on the history, science, and various cosmetic applications of this drug at the annual meetings of the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgery (ASPS).

Fagien has authored dozens of journal articles relating to botulinum toxin. In 2004, he—along with Rod J. Rohrich, MD, FACS, and others—collaborated on the supplement to the Journal of Plastic and Reconstructive Surgery that was entirely dedicated to the cosmetic use of botulinum toxin. Also last year, he—along with Jean Carruthers, MD, FRCS(UK), FRCS(C); and Seth Matarasso, MD—edited the “Consensus Guidelines” article that appeared in the Journal of Plastic and Reconstructive Surgery. The article contained guidelines established by a group of experts from all specialties for the variety of facial aesthetic uses of botulinum toxin.

How many patients, on average, do you treat with botulinum toxin?

On average, I treat 30 to, at times, more than 50 patients a week. It composes at least 20% to 25% of my practice.

What is the average cost for a botulinum toxin procedure performed in your office?

In my practice, the average cost is about $750; but the range can be anywhere from $600 to more than $1,000, depending on the number and extensiveness of the areas to be treated.

For which procedures do you use the drug, and which are the most common?

The three standard sites that people traditionally present for are the glabellar frown lines (the vertical lines between the brows), the lateral canthal lines (crow’s feet), and the horizontal forehead furrows. The problem with treating any one of those areas is the fact that if you’re really treating a single region, a large part of the reason you’re treating it is for line eradication. When you isolate certain regions only, you’re missing an opportunity to treat the next dimension, which is facial shape. When you treat the horizontal forehead furrows by treating the forehead instead of treating the lines, you can influence how you can shape the forehead and eyebrow. When you treat the outer canthus for the lateral canthal crow’s feet, you can also change the shape of the outer corner of the eye, as well as the position of the lateral eyebrow. You start to then take a drug that was used primarily for treating and erasing lines, and apply it to improving the shape of facial soft tissue. Why those three procedures became popular is because patients and practitioners alike saw a line and wanted to treat it with botulinum toxin. In thinking along those terms, they either ignored or were not fully aware of the potential negative ramifications when they considered treating a line and didn’t consider what that can do adversely to facial shape and adjacent soft-tissue position. For instance, if you treat somebody who has dense horizontal forehead furrows, and you don’t think about why the furrows are there, you lose sight of the fact that they’re probably there because the patient is always raising their brows. So when you treat those and eradicate the forehead furrows completely, you can make their forehead as smooth as a bowling ball; but you didn’t take into account that their brows are probably going to drop to their upper eyelashes! If you watch how people animate, it can tell you a lot about what will happen if you change that. I look at how people animate during my interview, whether I’m interviewing them to consider them for botulinum toxin or for surgery. So, if you treat horizontal forehead furrows indiscriminately, and are not conscious of the fact that it will alter the forehead animation and brow position, you’re going to get a lot of unhappy patients who get significant induction of brow ptosis and inanimate foreheads. The same thing occurs with all the other areas of the face.

The way you apply botulinum toxin to your patients, in my opinion, should follow the same principle and concept that you use with surgery: You don’t really want to alter people unless they truly desire alteration; you want to make people look better and look like they didn’t do anything. When you see somebody who so obviously has had botulinum toxin, it’s usually because it’s not an optimal result.

I completed an investigator-initiated study on the use of the drug for the treatment of vertical lip lines. I realized early on that with using low-dose botulinum toxin in the lips to reduce those lines, you want to avoid or minimally affect function so patients can still purse their lips; yet they don’t purse as forcefully and the lines appear to be better, inasmuch as the fact that if you use fillers in the lips to make them look plumper and to get rid of lines, the effects of the fillers are attenuated by the fact that the active movement of the mouth doesn’t make any (nonpermanent) filler material stay very long. You can use small amounts of botulinum toxin to make the lines better; and if you’re using it in conjunction with the filler, it makes your filler last longer. The study confirmed the efficacy of this application. However, you have to reduce your doses of botulinum toxin in the lips dramatically so that patients can maintain lip competence.

So, we started expanding the use of botulinum toxin to the mid- and lower face, going from the upper third of the face, which is still the most common area to treat, to the midface—the bunny lines, which are the little scrunched lines near the inner corner of the eye at the lateral nasal bridge. Some people treat the nasal labial folds. I think that is a relatively weak application for botulinum toxin. Most of the time when you treat the nasal labial folds, you alter the smile significantly.

In the lower face, a common area and particular muscle that I treat is the depressor anguli oris—the muscle that extends from the outer corner of the mouth to the jawline, and depresses the lip and the outer corner of the mouth. This is the cause, in part, for the furrowing that we get that causes the appearance of jowls and a little bit of the downturn of the corner of the mouth. With at least half of the patients that I treat with botulinum toxin somewhere else on the their face, I also treat these depressor muscles to make their mouth and lips look better, because it can raise the corner of their outer oral commisure. Also, I now commonly inject a filling agent along the jawline, because they’re losing that fat and getting that depression that is sometimes called the “perimental hollow.” If you put a little botulinum toxin in the depressors, patients can actually retain their fillers longer. So again, you’re using botulinum toxin primarily to improve the shape, but you’re also doing it to make the filler last longer.

We’re gaining a better understanding how botulinum toxin is a partner with fillers. More often than not, patients are coming to see me for both. As surgeons, we’ve always figured that most problems had a surgical solution. Now, we’re realizing that there are nonsurgical methods to make people’s faces look better, including adding volume. There’s a huge role for minimally invasive injectable treatments for facial rejuvenation.

What is your technique(s) in these procedures?

The technique usually is very much dependent on what area you’re treating. The whole idea with getting a good result is, first, understanding the facial anatomy and the muscles that cause the changes that you want to correct; and, second, being extremely precise in the application of the drug so that the drug is going exactly where you want it to go in the muscle you want to affect. This minimizes the diffusion into other adjacent muscles, which may give you unwanted, undesirable, or surprising effects. The bottom line is that it really doesn’t mater what your technique is; it matters where the tip of the needle is. Ultimately, it is the result that matters. The exact technique, however, will very much depend on what region you’re treating.

For instance, while treating the glabellar region for the improvement of furrows, I have often seen even “expert injectors” injecting in a way that I know can’t possibly be precise. When people talk about treating the glabella region, they primarily are thinking about how they treat the corrugator muscles, which pretty much ride within or just above the medial half of the eyebrow. I have observed individuals inject more than a centimeter above the eyebrow, and the corrugator simply doesn’t live there. So what do they get? You can get secondary effects from diffusion, so that the corrugator does eventually get some weakening (even if you’re injecting around it); but the problem is that now you’ve injected a lot to the frontalis muscle—the forehead-elevating muscle—and when you do that, you’re going to depress or drop the medial brow. That may be an effect in some that’s acceptable; in others it is just aesthetically horrendous. Similar errors occur when these injections are given too superficially, whereby the effects are primarily on the frontalis muscle and less to the corrugator muscles that lie deep to this.

My technique is that I make a precise injection into the belly of the corrugator muscle. I use my nondominant hand, with my thumb underneath the brow and my forefinger above it, and I roll the eyebrow over the superior orbital rim. In doing so, I pull the soft tissue away from the orbit and am able to grasp the corrugator essentially between my finger and thumb. I am then able to perceptually inject directly into the belly of the corrugator, knowing that I am avoiding an intraorbital injection.

Some people also “ultra-dilute” the drug and have to put in a lot of volume to get an effect. When you put a lot of volume anywhere, you’re going to get diffusion into other areas. You need to keep your volumes reasonably low to avoid the amount of fluid that’s going to be injected, which will also reduce diffusion.

In contrast, regarding the horizontal forehead furrows, it doesn’t matter (much) in which plane that you inject the forehead. It’s the only active muscle there. You can do it intramuscularly, submuscularly, or subdermally. It seems to work anywhere in the forehead. You are probably more efficient while injecting directly into the muscle, but this can cause, in some, a significant amount of bruising. In distinction, I like the orbicularis muscle treatment to the crow’s feet to be immediately subdermal. As it is generally a thin and diffuse muscle that lies just beneath the skin, a subdermal injection is probably equally as effective as an intramuscular injection—without the bruising.

The mouth or perioral region is also an area in which people are requesting treatment more frequently. The lips can be sensitive to pain more than other areas, so I roll an ice cube over the lips for a minute or two. Then I place one injection on either side of Cupid’s bow—typically a unit to a unit-and-a-half per site—midway between Cupid’s bow and the lateral commissure. Usually it’s an immediate subdermal injection, to limit bruising. This is one area where the higher you inject away from the vermilion border, the more you start to affect the lip elevators, which can also affect smiling, The best and most accurate way is to inject closer to the vermilion border.

Is there any other advice that you would give to others in the field?

I think the novice injector should start slowly using lower doses in areas they’re unfamiliar with—specifically, the lower face. There are more muscles in the lower face that are going to be affected by diffusion than in the upper face, and it’s far more difficult to be precise unless you’ve had a lot of experience. Most of the problems with any of these agents relate very little to the drug itself, and more to what is—or who is—proximal to the syringe. You need to observe a master, someone who has had a lot of experience and sometimes does things so intuitively that they can’t even explain it; but as you watch them, you see the things they do—and, more importantly, the things they don’t do—to get the best results.

What new applications of botulinum toxin do you find interesting?

Regarding some of the more functional uses, the recent labeling for hyperhidrosis (excessive perspiration) is interesting and obviously has yielded great demand. You have a lot of cases where it’s a lifesaver to those people, especially by dramatically improving their quality of life. Facial spasticity, as well as generalized body spasticity, is another noncosmetic use of botulinum toxin. New applications are being discovered, even in spinal cord/nerve regeneration and wound healing. You can improve your results from surgery by temporarily immobilizing the area, which tends to improve scarring. There’s a lot of science going into neurotoxin study, and that’s exciting for functional uses of botulinum toxin.

Another one of my discoveries has also gained significant interest lately: the treatment of mild to moderate upper-eyelid ptosis with botulinum toxin. The greatest concern, still, that new patients relay is getting “a droopy eyelid” from the treatment. It is interesting how this fear is dissipated when patients are told that the drug can actually be used as a treatment for drooping eyelid. I probably treat at least one patient a day for a mild to moderate upper-eyelid ptosis with botulinum toxin. Facial reshaping is a really exciting application. I use low-dose botulinum toxin on the eyelid to improve eyelid shape. Someone who has a mild droop of their upper eyelid or a lid malposition or asymmetry, and is not particularly interested in surgery at the time, now has an effective, nonsurgical—albeit temporary—treatment option.

Danielle Cohen is a contributing writer for Plastic Surgery Products.