Rejuvenating the periorbital areawith Botox

by Dr. Patrick Treacy

Medical DirectorAilesbury ClinicsDublin Ireland

LECTURE SERIES ON THE COSMETIC USES OF BOTULINUM-A TOXIN

ANATOMY OF THE PERIORBITAL AREA

CORRECT PATIENT

SELECTION

HOW TO PROPERLY EVALUATE THE AREA

TIPS AND TRICKS

Anatomy of the periorbital area

Muscle Anatomy (A) Frontalis (B) Corrugator superciliaris (C) Procerus (D) Orbital Orbicularis

(E) Preseptal Orbicularis (F) Pretarsal Orbicularis

ANATOMY OF PERIORBITAL MUSCLES

ORBICULARIS OCULI

Action:Depresses eyebrows Closes the eyelidsHelps drainage of tears

OriginMed orbital margin and lacrimal sac(orbital, palpebral and lacrimal parts)

InsertionLat palpebral raphe

Anatomy of Orbicularis Oculi

Orbicularis is a curved muscle running from the medial orbital margin to the frontal process of the maxilla.

A

B

C

ORBITAL (A) is used in forced closure of the eye

PALPEBRAL (B) is used in blinking and voluntary winking

Anatomy of Orbicularis oculi

(D) ORBICULARIS OCULI

Superficial muscle of facial expression.

The muscle is divided into the ORBITAL and PALPEBRAL

The PALPAEBRAL is divided into

Preseptal (E) Pretarsal (F)

ANATOMY OF FOREHEAD MUSCLES

CORRUGATOR SUPERCILII

Action: Depresses eyebrows and wrinkles forehead

Origin Medial superciliary arch

InsertionSkin of medial forehead

ANATOMY OF FOREHEAD MUSCLES

FRONTALIS

Action: Elevates eyebrows and the skin of the forehead

OriginOccipital:highest nuchal line and mastoid process. Frontal: sup fibres of upper facial muscles

InsertionGaleal aponeurosis

EVALUATE DEPTH ORBITAL SOCKET

IS THE EYE SOCKET DEEP OR SHALLOW?

DOES THE PATIENT’S INFRAORBITAL RIM PROTRUDE?

CHECK SKELETAL SUPPORT OF LOWER LID WITH THE ‘PENCIL’ TEST

IF PENCIL IS CLOSE TO CORNEA THERE IS A GREAT RISK OF INFRAORBITAL CONTENTS BULGING

EVALUATE ORBICULARIS TONE

ARE THE WRINKLES DEEP?

SPREAD THE SKIN BETWEEN

YOUR FINGERS

DO THE ‘TOUCH’ TEST BY PRESSING LIGHTLY ON

ZYGOMATIC AND ASK PATIENT TO SMILE

THIS SIMULATES THE POTENTIAL ACTION OF BOTOXBY STOPPING

ORBICULARIS CONTRACTION

EVALUATE THE AESTHETICS

OF THE FACE

IDEAL PROPORTIONED BROW SHOULD BE 1/3 FACIAL HEIGHT

AS MEASURED FROM HAIRLINE TO GLABELLA

WOMEN SHOULD BE GENTLY ARCHING

AND SHOULD LIE JUST ABOVE ORBITAL RIM

HIGHEST POINT SHOULD LIE BETWEEN LAT LIMBUS AND LAT CANTHUS

EVALUATE THE AESTHETICS

OF THE BROW

LATERAL BROW ASPECT SHOULD BE HIGHER THAN MEDIAL ASPECT

THIS PARALLELS FREE MARGIN OF LAT ASPECT OF

EYELID

HIGHEST POINT SHOULD LIE BETWEEN LAT LIMBUS AND LAT CANTHUS

EVALUATE FACIAL ASYMMETRIES

• SHOW TO PATIENT• DOCUMENT AT TIME • PHOTOGRAPH IT BEFORE PROCEDURE

DANGER IS THE POSSIBILITY OF EXACERBATING PRE-EXISTING OR UNDERLYING BROW OR LID PTOSIS

EVALUATE AMOUNT OF HOODING

ESTABLISH WHETHER THE PATIENT CAN APPLY MAKE UP

PHYSICALLY GRIP SKIN TO SEE AMOUNT OF REDUNDANT TISSUE

CHECK TO SEE IF DEEP SET EYES OR LID HOODING

PATIENT MAY BE SUITABLE FOR LATERAL BROW LIFT

CASE 1 Patient with assymetrical face post nerve CASE 1 Patient with assymetrical face post nerve damagedamage

CASE 1 Patient with nerve damage post CASE 1 Patient with nerve damage post craniotomy craniotomy

CASE 1 Placement of Contour Threads CASE 1 Placement of Contour Threads

Placement of Contour Threads Placement of Contour Threads

CASE 1 Correction with Contour Threads CASE 1 Correction with Contour Threads

EVALUATE INFRAORBITAL FAT PADS

LOOK FOR A WEAK ORBITAL SEPTUM OR PROTRUDING FAT PADS

AVOID INJECTING INFERO- MEDIALLY IN PATIENTS WITH EXCESSIVE SKIN AND FAT.

PRETARSAL DRIFT CAUSES TEMPORARY EYEBAGS.

ACCESS LEVEL OF UNDERLYING HERNIATION BY PRESSING GENTLY ON ‘EYEBALL’

EVALUATE POSITION OF LATERAL ASPECT OF EYEBROW

SOMETIMES THIS CAN BE DIFFICULT

BECAUSEOF PATHOLOGY

SUCH AS HYPOTHYROIDISM

BE CAREFUL OF PATIENTS WEARING JEWELLERY

EVALUATE INFRAORBITAL VESSELS

BEST SEEN WHEN PATIENT LYING AT ANGLE OR SUPINE

PREFERABLE INJECT AS SUBDERMAL BLEB TO AVOID

TEMPORAL VESSELS

EVALUATE LEVEL OF WRINKLES

THESE PATIENTS OFTEN HAVE ‘GRID’ PATTERN OF LINES EXTENDING ALONG LATERAL ORBIT AND CHEEK AREA

BE REALISTIC WITH THESE PATIENTS OFTEN RISKS OF PROBLEMS ARE HIGHER IN OLDER PATIENTS USING BOTOX FOR FIRST TIME

BE AWARE OF AGING SUNDAMAGE SLEEP LINES

EVALUATE LID LAXITY

EVALUATE LID LAXITY WITH A SNAP TEST.

LAXITY INDICATES POTENTIAL FOR DEVELOPING LOWER LID PTOSIS AND INJECTIONS SHOULD BE AVOIDED

DANGER IS THE POSSIBILITY OF CAUSING ECTROPION

“SNAP”

EVALUATE FOR HYPERTROPHIC ORBICULARIS

SOME PATIENTS FAVOUR WIDER ROUNDED EYE

SMALL AMOUNT OF BTX-A INJECTED INTO THE LOWER PRETARSAL ORBICULARIS OPENS THE PALPEBRAL APETURE AT REST AND AT SMILE

EVALUATE ZYGOMATIC ARCH

EXAMINE HEIGHT AND WIDTH OF ZGYOMATIC ARCH

DOES ORBICULARIS MUSCLE SAG BETWEEN CHEEKBONE AND EYE

AREA WILL DEVELOP A HOLLOW APPEARANCE IF ORBICULARIS WEAKENED BY INJECTION

CAREFUL OF NEUROTIC PATIENTS

BE EVER WATCHFUL FOR PATIENTS TESTING YOU WITH SCARS

BE CAREFUL OF PATIENTS WHO TALK ABOUT OTHER DOCTORS

BE CAREFUL OF PATIENTS WHO HIDE PROCEDURES

BE CAREFUL OF PATIENTS WITH DEPRESSION

EVALUATE POSITION OF INFERIOR ASPECT OF EYE AREA

CORRECTION OF RHYTIDS EXTENDING OVER ZYGOMATIC ARCH INTO MALAR AREA

HOLD FINGER OVER THE INFEROLATERAL TO

LATERAL CANTHUS TO CHECK ON FINAL EFFECT

....

EVALUATE POSITION OF INFERIOR ASPECT OF EYE AREA

CORRECTION OF RHYTIDS EXTENDING OVER ZYGOMATIC ARCH INTO MALAR AREA

EXTRA INJECTION INFEROLATERAL TOLATERAL CANTHUS

....

BE CAREFUL OF PATIENTS WITH

PREVIOUS SURGERY

CAUTION WITH PATIENTS THAT HAVE HAD PREVIOUS SURGERY i.e.BLEPHAROPLASTY. THIS LEADS TO AN ALTERED PERIORBITAL ANATOMY.

BE CAREFUL OF VISION REFRACTIVE PROCEDURES i.e. (LASIK) LASER ASSISTED IN SITU KERATOMILEUSIS

LATERAL CANTHAL INJECTIONS

PERFORM 3 or 4 subcut INJECTIONS ABOUT

1 cm lat TO ORBITAL RIM

2-3 U per injection site ( total 6-12 U per side).

SPACE 0.5-1 cm APART IN ARCHING LINE

PLACE OUTSIDE BONY ORBITAL MARGIN

INJECTING PERIORBITALINJECTING PERIORBITAL

X= CROWS FEET Y= LATERAL BROW LIFT Z= RELAX INFRAORBITAL FOLDS WIDER OCULAR APETURE

OX

X

X

AILESBURY CLINIC 2004

BROW LIFT

INJECTING PERIORBITALINJECTING PERIORBITAL

X= CROWS FEET Y= LATERAL BROW LIFT Z= RELAX INFRAORBITAL FOLDS WIDER OCULAR APETURE

OX

X

X

AILESBURY CLINIC 2004

LOWER EYELID

REMEMBER brow POSITION is maintained by a BALANCE between DEPRESSORS and ELEVATOR

PROCERUS MUSCLECORRUGATOR MUSCLEORBICULARIS OCULI

FRONTALIS

FINAL BALANCE DEPENDS ON YOUR SKILL

IF YOU OVERTREAT FRONTALIS YOU PAY THE PRICE

NOW! HOW DO I GET BACK UP?

INJECTING THE INJECTING THE GLABELLA GLABELLA

X=NORMAL INJECTION POINTS IN MOST PATIENTS Y=LATERAL BROW LIFT SOMETIMES REQUIRED

Z= ADDITIONAL INJECTION POINT TO FLATTEN BROW

AVOID INJECTING LACRIMAL PUMP

LACRIMAL PUMP CONTAINS FIBRES OF ORBICULARIS THAT INSERT INTO LACRIMAL SAC.

PROCEED WITH CAUTION TREATING PATIENT WITHHISTORY OF DRY EYES

AVOID OVER-INJECTING BUNNY LINES

AVOID INJECTING LEVATOR LABII ALAEQUE NASI AND LEVATOR LABIISUPERIORIS TO PREVENT DROOPING OF UPPER LIP

DO NOT MASSAGE AREA AFTER TREATMENT

BE CAREFUL OF UPPER LIP PTOSIS

LEARNING THE INJECTION POINTS

GLABELLAR: INJECT 3-5 SITES ON EACH SIDE OF

THE MIDLINE

ABOUT 3-6U VOLUME BTX-A PER SITE

DANGER: AVOID INJECTING 1CM ABOVE MID-PUPILLARY LINE

SEPARATE INJECTION SITES

BY 1-2CMS

Remember to inject BTX-A in the GLABELLAR area in a V-formation

INJECTION OF THE GLABELLAR AREA

1. Place the first injection into the belly of the corrugator muscle

2. Advance the needle within the belly of the muscle upward and lateral as far as the medial 1/3 of the eyebrow, 1 cm superior to the orbital rim

3. Inject 1 cm above the upper medial aspect of the supraorbital ridge

INJECTING THE FRONTALIS AREA

FRONTALIS: INJECT 3-5 SITES ON EACH SIDE OF

THE MIDLINE

ABOUT 1-4U VOLUME BTX-A PER SITE

DANGER: AVOID INJECTING 1CM ABOVE MID-PUPILLARY LINE

SEPARATE INJECTION SITES

BY 1-2CMS