COSMETIC Nonsurgical Periorbital and Brow Rejuvenation Michael A. C. Kane, M.D. New York, N.Y.
Background: There is a high patient demand for periorbital rejuvenation because the periorbita are often the first facial areas to show visible signs of aging. In addition to rhytides and skin laxity, aging appearance of the periorbital area is caused by changes in tissue volume resulting from soft-tissue atrophy and bone loss in the aging face. These changes are among the easiest areas to correct using several noninvasive techniques. The author uses three different techniques in his practice. Methods: The author shares his experience using three different techniques for nonsurgical periorbital rejuvenation. Results: Patients develop unique crow’s feet lines, and treatment with toxins should be adapted to each particular pattern. Low doses generally produce a more natural appearance than high doses. Using hyaluronic acid fillers, three tissue layers within the periorbita can be injected to produce maximally beneficial results and minimize the risk of adverse events. Filling tear troughs depends on whether they occurred early in life or are age-related. The key to avoiding complications is a careful patient analysis and a slow technique. Conclusions: One deformity should not be singled out when rejuvenating the periorbita. The best results are obtained when the entire periorbital area is treated at the same time. (Plast. Reconstr. Surg. 135: 63, 2015.)
T
he periorbital areas are often the first facial areas to show visible signs of aging. Consequently, there is a high patient demand for periorbital rejuvenation. The aging appearance of the periorbital area is attributable to much more than just the development of rhytides and skin laxity. Changes in tissue volume result from soft-tissue atrophy and bone loss. Similar to other areas of the body, bone loss in the aging face causes volume loss and morphologic changes to the orbit and the midface.1 The width and area of the orbital aperture increases significantly with age for both men and women.2,3 This includes a significant recession of the superomedial and inferolateral orbital rims. Loss or ptosis of deep fat compartments in the aging face leads to changes in shape and contour.4 Together, the changes in skin, underlying soft tissue, and bone contribute to the appearance of the aging face, requiring multiple facial rejuvenation procedures for maximal rejuvenation. Fortunately, these changes are among the easiest to correct using several nonsurgical techniques, From Manhattan Eye, Ear, and Throat Hospital. Received for publication December 19, 2013; accepted March 20, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000831
giving patients a relatively large aesthetic return for limited downtime and a high degree of satisfaction. I use three different synergistic techniques in my practice.
BOTULINUM TOXIN One of the most common complaints among aging patients is the appearance of lateral canthal rhytides or crow’s feet lines in repose. All crow’s feet patterns are not the same, and it follows that treatment of different patterns of crow’s feet lines should be adapted to the particular patterns of motion. Everyone smiles a little differently, resulting in several different patterns of animation.5 One must pay attention to the dominant neuromotor units and try to relax them by injecting more toxin into that area. Use of smaller doses and smaller aliquots “dribbling away” from the strongly injected muscle create a gradient of relaxation and thus a gradient of motion across the area. Low doses with a gradient of motion are both rejuvenative and Disclosure: The author is a consultant for and stockholder in Allergan; a consultant and investigator for Valeant and Teoxane; a consultant for Merz and Galderma; a consultant and investigator for and holder of stock options in Revance; and an investigator for Coapt.
www.PRSJournal.com
63
Plastic and Reconstructive Surgery • January 2015
Fig. 1. (Above, left) This woman in her forties is seeking rejuvenation of her upper face, especially her brow asymmetry. She is frowning before injection. She was last treated with botulinum toxin type A 5 months previously. (Above, right) Four weeks after injection of her glabella and nasalis. She is unable to frown or lower her medial brows after injection of 20 units of incobotulinumtoxinA into her corrugators and procerus and 2.5 units into her nasalis muscle. (Below, left) The patient is raising her eyebrows before injection. Note the asymmetry, with the left forehead apparently stronger and the left brow noticeably higher than the right brow. (Below, right) The patient is raising her brows 4 weeks after injection of 5 units of incobotulinumtoxinA into her frontalis. Her frontalis muscle was injected asymmetrically, with 3 units into her left side and 2 units into her right side. This was done in an attempt to raise her right brow more than her left. To maximize brow lift, a moderate amount of motion was left, resulting in small frontal rhytides apparent on extreme animation. (Copyright © Michael A. C. Kane, M.D. Previously published in Kane MAC. Botulinum toxin. In: Neligan RC, ed. Plastic Surgery. Vol. 2, 3rd ed. Philadelphia: Saunders; 2012:30–43.)
natural. An unnatural appearance after injection of botulinum to the crow’s feet generally occurs for two reasons: the entire area is overdone and appears flat or a small area is overdone, immediately bordered by areas of compensatory hyperkinetic facial lines. My current median dose of onabotulinumtoxinA and incobotulinumtoxinA in this area is 5 units, and the median dose of abobotulinumtoxinA is 12 units.
64
When injecting the crow’s feet or lateral orbicularis oculi, I usually inject partly across the lateral lower eyelid approximately at the junction of the pretarsal and preseptal orbicularis oculi. A minimal amount of toxin is used (
Background: There is a high patient demand for periorbital rejuvenation because the periorbita are often the first facial areas to show visible signs of aging. In addition to rhytides and skin laxity, aging appearance of the periorbital area is caused by changes in tissue volume resulting from soft-tissue atrophy and bone loss in the aging face. These changes are among the easiest areas to correct using several noninvasive techniques. The author uses three different techniques in his practice. Methods: The author shares his experience using three different techniques for nonsurgical periorbital rejuvenation. Results: Patients develop unique crow’s feet lines, and treatment with toxins should be adapted to each particular pattern. Low doses generally produce a more natural appearance than high doses. Using hyaluronic acid fillers, three tissue layers within the periorbita can be injected to produce maximally beneficial results and minimize the risk of adverse events. Filling tear troughs depends on whether they occurred early in life or are age-related. The key to avoiding complications is a careful patient analysis and a slow technique. Conclusions: One deformity should not be singled out when rejuvenating the periorbita. The best results are obtained when the entire periorbital area is treated at the same time. (Plast. Reconstr. Surg. 135: 63, 2015.)
T
he periorbital areas are often the first facial areas to show visible signs of aging. Consequently, there is a high patient demand for periorbital rejuvenation. The aging appearance of the periorbital area is attributable to much more than just the development of rhytides and skin laxity. Changes in tissue volume result from soft-tissue atrophy and bone loss. Similar to other areas of the body, bone loss in the aging face causes volume loss and morphologic changes to the orbit and the midface.1 The width and area of the orbital aperture increases significantly with age for both men and women.2,3 This includes a significant recession of the superomedial and inferolateral orbital rims. Loss or ptosis of deep fat compartments in the aging face leads to changes in shape and contour.4 Together, the changes in skin, underlying soft tissue, and bone contribute to the appearance of the aging face, requiring multiple facial rejuvenation procedures for maximal rejuvenation. Fortunately, these changes are among the easiest to correct using several nonsurgical techniques, From Manhattan Eye, Ear, and Throat Hospital. Received for publication December 19, 2013; accepted March 20, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000831
giving patients a relatively large aesthetic return for limited downtime and a high degree of satisfaction. I use three different synergistic techniques in my practice.
BOTULINUM TOXIN One of the most common complaints among aging patients is the appearance of lateral canthal rhytides or crow’s feet lines in repose. All crow’s feet patterns are not the same, and it follows that treatment of different patterns of crow’s feet lines should be adapted to the particular patterns of motion. Everyone smiles a little differently, resulting in several different patterns of animation.5 One must pay attention to the dominant neuromotor units and try to relax them by injecting more toxin into that area. Use of smaller doses and smaller aliquots “dribbling away” from the strongly injected muscle create a gradient of relaxation and thus a gradient of motion across the area. Low doses with a gradient of motion are both rejuvenative and Disclosure: The author is a consultant for and stockholder in Allergan; a consultant and investigator for Valeant and Teoxane; a consultant for Merz and Galderma; a consultant and investigator for and holder of stock options in Revance; and an investigator for Coapt.
www.PRSJournal.com
63
Plastic and Reconstructive Surgery • January 2015
Fig. 1. (Above, left) This woman in her forties is seeking rejuvenation of her upper face, especially her brow asymmetry. She is frowning before injection. She was last treated with botulinum toxin type A 5 months previously. (Above, right) Four weeks after injection of her glabella and nasalis. She is unable to frown or lower her medial brows after injection of 20 units of incobotulinumtoxinA into her corrugators and procerus and 2.5 units into her nasalis muscle. (Below, left) The patient is raising her eyebrows before injection. Note the asymmetry, with the left forehead apparently stronger and the left brow noticeably higher than the right brow. (Below, right) The patient is raising her brows 4 weeks after injection of 5 units of incobotulinumtoxinA into her frontalis. Her frontalis muscle was injected asymmetrically, with 3 units into her left side and 2 units into her right side. This was done in an attempt to raise her right brow more than her left. To maximize brow lift, a moderate amount of motion was left, resulting in small frontal rhytides apparent on extreme animation. (Copyright © Michael A. C. Kane, M.D. Previously published in Kane MAC. Botulinum toxin. In: Neligan RC, ed. Plastic Surgery. Vol. 2, 3rd ed. Philadelphia: Saunders; 2012:30–43.)
natural. An unnatural appearance after injection of botulinum to the crow’s feet generally occurs for two reasons: the entire area is overdone and appears flat or a small area is overdone, immediately bordered by areas of compensatory hyperkinetic facial lines. My current median dose of onabotulinumtoxinA and incobotulinumtoxinA in this area is 5 units, and the median dose of abobotulinumtoxinA is 12 units.
64
When injecting the crow’s feet or lateral orbicularis oculi, I usually inject partly across the lateral lower eyelid approximately at the junction of the pretarsal and preseptal orbicularis oculi. A minimal amount of toxin is used (
